Problem 1 – why were they left with no ongoing support?

As Dad is young, he slipped through the net of adult social care. Apart from a home visit 3.5 years ago, my parents have been left to deal with the dementia by themselves. No one knew who should pick his care up. Just before Christmas, we hit crisis point – Dad’s behaviour was becoming far too difficult and unpredictable for one person to handle. 

In February, we’d had another home visit and a checklist assessment was carried out. This was the first step towards help through an NHS Continuing Healthcare assessment. 

Problem 2 – No protocol in place for adults with young-onset dementia

Fast forward a month, and adult social care has washed their hands of Dad. Even though he’s an adult, he doesn’t fall under their team. He falls under the mental health team – and even though they work in the same building, his case hasn’t been transferred internally. The request for help has to be resubmitted. So, we start again. 

Problem 3 – COVID-19 hits

The COVID-19 pandemic is a stressful time for all of us. But for carers, there’s an extra layer of uncertainty – how long will any respite or day care continue, before they’re left out in the cold?

More pressingly for our family, Dad’s care home went into lockdown while he was there for respite. It meant we faced the agonising choice – leave him there for the foreseeable, or know that we would have no help, support or relief from his 24-hour care needs. We opted to leave him there.

A few weeks later, the fever started. The next day, his persistent cough developed. The care home wanted him out and asked my mother to collect him – against all Government and NHS advice. They risked him passing it onto her. My initial concern was if he did, who would call for help if she needed it? 

The situation calmed and he has been allowed to stay for at least the remainder of his period of self-isolation. But, while he’s there he’s just sitting alone in his room. No one to talk to, no comprehension of what’s going on outside. Nothing. What will he be like after self-isolation? Will his dementia deteriorate rapidly? Will he recognise anything afterwards? Only time will tell. 

Problem 4 – the financial assessment

As part of NHS Continuing Healthcare funding, the adult social care element requires a financial assessment. (Yes, you’ll note adult social care is apparently taking an interest now money is involved.) They ask that you try to fill in the mammoth form within 7 days. It’s overwhelming, especially in the middle of a stressful situation. You’re given no information as to what support package you might be offered – but expected to give out some of the most personal details about yourself. 

The pandemic has exacerbated an already overburdened sector. There’s no face-to-face support for those overwhelmed with documentation. There’s no time to explain what it all means. There’s no time for help for those who need it.

How can the Government help?

Government has stepped in to provide much needed help and support to many people – but their job is essentially fighting fires. Adult social care is a ticking time bomb, and it’s putting people’s lives at risk. I’ve three asks of them:

• Care assessments must continue.
• Care homes must treat those with COVID-19 in line with NHS and Government guidance.
• Adult social care services must be adequately funded to allow them to fulfil their duties and provide support during this nightmare time.

We are all impacted in different ways, both staff and patients. Whether it’s even more time at work, less time with those we love, wanting to be at work but having to self isolate, loss of our identity as the one who always does x or y, how as patients we interact with our NHS, or the loss of those we love.

Transitions are challenging

William Bridges says it isn’t the changes that do you in, it’s the transitions. Change is something that happens to people, even if they don't agree with it. Transition, on the other hand, is internal. It's what happens in people's minds as they go through change. Change can happen very quickly, while transition usually occurs more slowly as we internalise and come to terms with the details of the new situation that the change brings about.

Stages of transitioning include:

• Ending - letting go of the old ways and the old identity.
• The neutral zone - going through an in-between time when the old is gone but the new isn’t fully operational, when the critical psychological re-alignments and re-patterning take place.
• New beginnings – when we come out of the transition and develop a new identity, experience a new energy and discover a new sense of purpose.

3 tips for dealing with transition

So what can we do to ease the transition? Here’s my three As for the day:

Acceptance

Accept that we will each make our transition at different paces. For some shock and denial through to acceptance and hope is rapid, for others it may take longer. So more than ever looking after each other is key. Steve Covey’s talks about making a deposit in the emotional bank account: understanding your friend, your colleague, a small act of kindness. What will be a deposit for you, may be a valuable withdrawal for them.

Appreciation

There’s already a zillion examples of people moving hell and high water to do what needs to be done to best respond to COVID-19, positive energy is thriving. Appreciating this is just as important. We can show our appreciation locally in our teams, on an individual basis or by joining the nation in clapping those who are helping to keep our world turning,.

Awareness

Be aware of high levels of anxiety and exhaustion in yourself and those around you. We are all stressed by different things. For some it’s spending too much time alone. Others ambiguity and uncertainty. Some will struggle most with decisions they think are illogical, last minute or require super human endeavours.   

Knowing our own limits and triggers and those of people around us is key. When you spot them, pause just for a vital moment, take a brief step back before anyone keels over and think through next steps. Explore information and ideas and talk them through with others. And where you can see that someone isn’t in a good place, give them permission to re-charge their batteries so their brilliance can continue to shine.

“Not in his goals but in his transitions man is great.” —Ralph Waldo Emerson

References

William Bridges, Bridges Transition Model, 1988.

Stephen R. Covey. The seven habits of highly effective people. Franklin Covey, 1990.

Previous blogs by Sally

Leading for improvement

Immunity to change

How a single piece of paper could help solve complex patient safety issues

The art of wobbling: Part 1

The art of wobbling: Part 2

You are 80 years old. You live independently and have a full social life with friends of similar ages. You have no close family; your friends are your family. You are very much part of the community and enjoy life.  

Every winter you get a ‘bad chest’. You visit the GP when this happens and get antibiotics. This is your only health issue.

Being locked down hasn’t been an issue for you. Life is different, but the village you live in has a great support network, you can get shopping delivered, you are connected via the internet to your activity groups – even tai chi on zoom!

You receive a phone call from your GP. They state "...with your chest, it's unlikely that you will survive this virus. So, I need to ask you... do you want to be placed on a ventilator and do you want to be resuscitated?"

They expect an answer while they are on the phone to you.

You have less than 5 minutes to respond.

"Errrrrr, yes… I have lots to live for, please do everything you can" is your reply. You put the phone down and cry. You are scared. What now?

This is a real case that was told to me this morning.  

‘Difficult conversations’ are needed. They have always been needed. Whether that be in primary care or secondary care, these conversations are important. It is important to find out what patients and families wishes are, important to offer informed choice of what treatments will be of benefit and important to manage expectations from both, patient, families and clinicians.

Much has been written on how to have these conversations, when to have these conversations and by whom – this advice has been written in a non-pandemic time where people have the time, have up to date, clear information that patients and families can discuss the issues.

Some GPs are using the RESPeCT document, its been slow to adopt and spread, but if completed makes the world of difference. Having an open conversation about dying may feel taboo, but you only get to die once (usually)… you may as well do it well.

Where I work clinically, all patients who are suspected COVID-19, have a treatment escalation form completed as they are admitted. This informs other clinicians what treatment that patient can receive during their admission. If a patient doesn’t have a treatment escalation discussion, patients may experience unnecessary pain, suffering or futile treatment that they didn’t want, but were unable to say.

The treatment escalation form and process we are using has transformed and streamlined our care. We are now able to give the right care to the right patient at the right time. Patients and families are fully informed and are grateful for having the conversation.

But what happens during the pandemic in primary care?

GPs are unable to wait for their patients to turn up to the surgery to have these conversations. Many of their patients are the most vulnerable, in care homes, the homeless and often difficult to reach.  

Is a telephone call, out of the blue the best way of having this conversation?

GPs have hundred, if not thousands of patients on their case load, how are they to have meaningful conversations during this pandemic with the most vulnerable?

This blog is not to highlight the bad practice. It is not a time for naming and shaming. We are learning together.

 Are you doing things differently? Do you have a solution? Are you a patient and have an idea on how we can do this better?

The study of human factors/ergonomics considers both the physical and mental characteristics of people, as well as wider organisational factors. It applies scientific methods to the design and evaluation of jobs, equipment, environments and systems to make them more compatible with the needs, capabilities and limits of people.[3]

How does this relate to the production of ventilators for use in healthcare? 

It’s important when designing and developing these machines to ensure their usability – that we account for the people who are using them. That means making sure they are as intuitive and easy to use for frontline staff as possible, reducing the potential for error. This is especially pertinent in the current crisis, where doctors and nurses who are not necessarily experts in the use ventilators will be deployed to operate these while working under considerable pressure. 

Ensuring that safety considerations are taken on board during the development and design of ventilators can help to reduce errors and ultimately save lives.

Procurement of new ventilators

Manufacturers are being actively encouraged by the Government to design and deliver the extra ventilators required to meet the increasing demand as a result of the coronavirus. To meet the scale of the challenge this includes not just established manufacturers of these products, but also companies who haven’t previously produced these machines. 

Understandably priority is being given to the fast delivery of additional ventilators. The Department of Health and Social Care has been 'weighing up whether manufacturers could come up with new designs, issuing specifications for a “minimally acceptable” rapidly manufactured ventilator system’.[4]

The importance of patient safety in design and development

The human factors/ergonomics experts that we have spoken to have noted that there will be risks to patient safety which are linked with the need to manufacture new ventilators as quickly as possible. There are already some existing patient safety issues that relate to the ease of use of ventilators, due to multiple designs of these machines being in use within the NHS, with different training requirements for different devices. It is important that when putting in place minimum standards to speed up production that we don’t create additional risks to patient safety.

It is also important to account for people who will be using these machines. Particularly those who may be inexperienced or untrained in the use of ventilators, meaning that ease of use is a crucial consideration when developing these. Another factor is how well you are able to operate these machines while wearing full personal protective equipment (PPE) when treating coronavirus patients.

There is a risk that by moving at speed and developing non-standard ventilators to reduced standards (some produced by manufacturers who don’t have prior experience in this area) that we may unintentionally be designing a system than has numerous points of failure, increasing risk for patients. 

Should ventilators fail to be safe in use, we may not even realise this, as patients who are already seriously unwell with coronavirus may have deaths as a result of these failures attributed to the virus itself.

The need is great, and the timescale is short

Due to the time constraints and urgency to produce new ventilators, a full human factors/ergonomics development and usability testing process is not possible. However, we are connecting with experts working in this area who are committed to collaborate to make these new ventilators as safe as possible. Human factors/ergonomics experts fundamentally want to ensure any product, particularly with relation to the safety, are usable and account for human error.

How we can ensure ventilator safety?

It is important that these ventilators are developed with the principle the residual risk is reduced as far as reasonably practicable.

It’s important that we build existing knowledge to bring in committed recognised experts and fast track the development of safe ventilators. Action is needed now. 

In the last 48 hours the human factors/ergonomics experts we have engaged have identified requirements and proposed actions:

1. Sharing current knowledge and expertise:

• Sharing usability testing from current manufacturers for the user interface/use specifications for already approved ventilators.

2. Contributing to this fast development of ventilators with specialist human factor/ergonomics and clinical input including:

• Safety in use is included in specification and procurement.
• Current knowledge of best practice and risk informs ventilator design and use.
• Ventilators can be used safely by staff.
• Patient needs are included in the design brief.

Their proposals include:

• Developing a set of user requirements.
• Human engineering and user trials with hazard identification.
• Human factors requirements must be included in procurement.

The healthcare system, working together with manufacturers and experts in human factors/ergonomics, can ensure that we not only deliver the ventilators needed to tackle the coronavirus pandemic, but that we do so while ensuring patient safety.

We call for everyone working at pace to deliver these ventilators to call on the knowledge and expertise of human factors/ergonomists to minimise the usability safety risks.

References 

1. Gov.uk. Call for businesses to help make NHS ventilators. Last Accessed 30 March 2020. https://www.gov.uk/government/news/production-and-supply-of-ventilators-and-ventilator-components

2. Financial Times. UK steps up efforts to supply tens of thousands of ventilators. 30 March 2020. https://www.ft.com/content/8eca845b-56c8-4724-bd77-d7d83c005bfb

3. Clinical Human Factors Group. What are clinical human factors? Last Accessed 30 March 2020. https://chfg.org/what-are-clinical-human-factors/

4. The Guardian. Government chooses design of ventilators that UK urgently needs. 23 March 2020. https://www.theguardian.com/business/2020/mar/23/carmakers-make-nhs-ventilators-coronavirus-uk-government-nissan-rolls-royce

We need to keep all patients safe

Healthcare professionals will be focused by this crisis with huge efforts being made into limiting the spread, protecting patients and keeping demand for health services down and to manageable levels. We must not forget about the adverse consequences this will have on others who need our services.

We need to assess the impact COVID-19 (CV19) will have on patient safety as existing patient safety issues will be magnified and exacerbated with the rapid escalation of CV19, known causes of these issues such as scarcity of workforce are likely to become even more significant and as CV19 will become the main focus of a large number of healthcare care staff patient safety initiatives that have to date had traction and success may be abandoned for expediency.

Patient, carers, family and friends perspective

Healthcare staff will be focused on treating the person in front of them and the associated risks of CV19 to that individual. Patients see their whole care journey. They are well placed to identify gaps quickly. The concerns and experiences shared by patients and their families will help us highlight bigger system issues that need addressing quickly to prevent avoidable harm during this pandemic. We need patient stories, we need everyone's and anyone's stories.

Knowledge sharing and collaboration for patient safety

We are collating insights into the impact on non CV19 patients and patient safety to inform healthcare leaders and afterwards for learning.

We are using Patient Safety Learning’s the hub, a dedicated knowledge-sharing platform and community for patient safety, to do this. This has a knowledge repository, communities of practice, news and invites members to share their resources and insights.

There is already a dedicated section of the hub that contains resources on coronavirus and CV19: guidance, advice, tips and personal experience blogs.

We have set up a separate section on our community and inviting patients, family members and staff to share their stories, highlighting weaknesses/safety issues that need to be addressed and sharing solutions that are working:

Stories from patients, carers, families

We are inviting people to share with us their stories and:

• A personal snippet of their life and personality (a photo would be great to make it personal)
• Where they live
• What part of the healthcare system they access and for how long have they been using it?
• What have they noticed that has been different now the crisis has started? E.g. outpatient appointments, collection of medication, GP appointments, cancellation of operations?
• What impact has this had on them?
• What are their fears about their long-term health problem in amongst the crisis?
• Do they feel safe?
• Do they feel informed?
• Contact details if they are happy to share.
• Highlight new areas of unsafe care. What have they noticed that has been different now the crisis has started, e.g. outpatient appointments, collection of medication, GP appointments, cancellation of operations?

Some of the issues we’re keen to look at are:

• Aspects of healthcare that you previously considered safe but maybe no longer be so as a consequence of fewer staff, changes in ways of working, unclear new arrangements etc.
• In cases of elective intervention and/or appointment being postponed, does the patient/family know the warning signs to call for help? Is there a hotline or urgent clinic for patients to contact?
• Positive stories as well as negative. Has anything improved since the crisis? For example, has the use of digital/virtual interventions (accessing a GP) had a positive effect?
• Data and analytics if available to show current trends in safety and adherence.

How we can engage with patient leaders to access patients’ stories

We are actively promoting the sourcing of insight from patients, families and staff. We will be actively promoting this through the patient safety agencies, patient and family organisations, healthcare systems, social and mainstream media in. We will promote as a campaign through #SafetyStories

What will we do with this insight and information?

This information will be publicly available on the hub for all.

We will review the content and identify themes of concern/worry and highlight as a global resource through regular updates and reports. These will highlight the ‘second victims' of the virus.

At Patient Safety Learning we are gathering #safetystories from both staff and patients to highlight the challenges for safety in healthcare that are resulting from the pandemic. Ahead of the Committee’s next oral evidence session we have raised several urgent safety issues with the Chair, Jeremy Hunt MP. The Committee should seek answers and actions from NHS leaders and politicians on the issues identified to ensure the safety of staff and patients. Below is a summary of our submission to the Committee, a full copy of which can be found here.

Personal Protective Equipment (PPE) for staff

There has been an increasing number of concerns raised by staff through the media over the past week around problems accessing appropriate PPE. While at a senior level there has been assurances about the availability of appropriate PPE for NHS staff, we are concerned that this is not being borne out by their experiences on the front-line, undermining trust and confidence that staff safety is being treated as a priority.

In our submission we’ve cited several issues raised by healthcare workers in this regard, such as discrepancies in the amount of PPE available to staff in some roles (e.g. ambulances) as opposed to others (e.g. emergency departments). There have also been concerns about the guidance provided on what PPE is required. We’ve been advised of incidents where this has been downgraded to reflect the availability of supplies; this is clearly highly risky and does not reflect a science-based response to the pandemic.

We’re asking the Committee to bring the following questions to the meeting, and to seek answers and action from NHS leaders and politicians:

• What is being done to ensure all ‘at risk’ staff have access to PPE, not only in the Intensive Treatment Units (ITUs) but Emergency Departments, Wards, Ambulances, in the community, everywhere?
• Who is in charge in every organisation to ensure that PPE is available and in use, according to robust guidelines? 
• How do staff report concerns and to whom? 
• What assurances are there that the safety of staff is paramount and that the cost of PPE is not preventing staff from having access to life-saving protection?
• How is the NHS supply chain communicating with trusts over likely lead times for PPE and availability of supplies? Is there transparency in this so that trusts can plan effectively how to use the stocks they have left?

Testing

There has been a number of reports about how the UK’s approach to testing differs from World Health Organization guidance and we’ve had concerns raised directly with us by staff who are genuinely fearful that they are infected and spreading the virus to their friends, family and the general public without knowing.

We’re asking the Committee to bring the following questions to the meeting, and to seek answers and action from NHS leaders and politicians:

• What is the policy for testing and tracing patients for Covid-19 in the UK?
• What are the requirements for test production and testing capacity in this country? 
• What are the plans and timescales to deliver this? 

We think that the scale of testing is compromising our ability to track the spread of the virus and isolate those that are infected.

Non Covid-19 care

Understandably the healthcare system is focusing its attention on the deadly effects of the coronavirus and we believe that we need to pay attention to patient safety now more important than ever. We are hearing stories of patients whose planned tests, elective operations, diagnostic procedures are being postponed or delayed while the health care system focuses on responding to the pandemic. It is important to assess the impact the coronavirus will have on other areas of care and ensure it does not magnify or exacerbate existing patient safety issues.

We’re asking patients to share their safety stories with us to highlight weaknesses or safety issues that need to be addressed and share solutions that are working, so we can seek to close the close the gaps that might emerge as a result of the pandemic.

We’re asking the Committee to bring the following questions to the meeting, and to seek answers and action from NHS leaders and politicians:

• What arrangements are being put in place to inform patients and families of any changes in non Covid-19 care during the pandemic?
• How are UK patients and families being informed about any such changes in their care?
• What should patients do if they notice new signs and symptoms?

References

[1] UK Parliament, Health and Social Care Committee: Preparations for Coronavirus, Last Accessed 25 March 2020.

[2] HSJ, Staff in ‘near revolt’ over protective gear crisis, Last Accessed 25 March 2020.

I have always been an organised person. When I say organised, I mean that the kids get to school, I get to work, dinner is cooked, clothes are fresh, the house is clean, and we have time for fun.

The last few days our worlds have turned upside down. The kids don’t go to school, my work is not what I know anymore and I’m too scared to go, dinners are not the usual (we had spam fritters and tinned potatoes last night), clothes are boiled washed, the house stinks of bleach and we can't go out.  

We shall get used to this new normal, I know that we all need to find a routine that will comfort us, even if that is making up new house rules or putting up a timetable for the kids (that went in the bin after 48 hours).

I’m getting used to being a bit of a crap mother at the moment. I’m getting a bit shouty, more than usual and I don’t like it. We are eating weird stuff I have found in the back of the freezer as I am limiting the amount of time I go out; I don’t recommend a frankfurter curry… bit salty.  

I'm trying to home-school the kids as the school will only take the boys when I’m at the hospital – this is to make sure everyone can get to work. If anything, this is what is going to send me over the edge first! The boys are fighting, they refuse to do the work set by the school, I try and help but I can’t understand it, they ask for snacks constantly, they want to go out with friends and, what with everyone online, the internet is slow. 

It’s been 48 hours of lockdown and I think I shall have an 'inset' day tomorrow.  

I know in my last blog I spoke of my husband and his business going a bit t***s up, it’s the least of the worries at the moment. The government has set out lots of support for him and his employees. He will be ok, his employees will be ok, we will be ok. This was a huge part of the stress we were under last week, but things have changed.

I have been doing extra shifts at the hospital to cover sickness. Many of our outreach team are in self-isolation due to family members being unwell or they are unwell. During these shifts I have witnessed the very best of our NHS and the Trust I work in, so why am I dreading my next shift?

Fear.

Never have I felt that my life is at risk during my 24-year nursing career. I have worked all over the world. Working in a refugee camp, being the only blonde, white woman, you would have thought I would feel scared or threatened. No, I was welcomed and respected. I have been driven at high speed in taxi in South Africa, racing away from armed car jackers when I was a repatriation nurse (admittedly this was a brown trouser moment), but it was one isolated incident. Being fearful of a job I love is so upsetting.

The medical admission unit is filling up with ‘red’ patients (COVID positive) and the ITU is starting to see its first patients. As an outreach nurse we are seeing the sick patients. They cough all over me. I have no idea if they have the virus or not. I am not wearing scrubs; I wear my outreach uniform which I launder at home, but I do have access to surgical masks, aprons and gloves.

A sick patient who is positive needs to go to the ITU. It’s my job to transfer them. I turn up with the ward nurse in an apron, gloves and surgical mask. They are wearing powerhoods or the N95 masks, scrubs, full plastic covering from head to foot, they have access to a shower after work and they have support from intensive care doctors. I feel totally underdressed and ill equipped.  

The nurses on the ward have been caring for this patient while wearing a surgical mask, apron and gloves. This patient was not receiving aerosoled treatment and the personal protective equipment (PPE) guidance is being followed, but I can’t help thinking that the wards are getting a raw deal.

They are working in a 'soup of droplets'. I caught a glimpse of one of the cleaning staff changing the curtains of the COVID positive patient who had left the ward to go to the ITU. He also had just a surgical mask and his normal uniform. I felt sad. I can’t help thinking that this isn’t right. I don’t think we have the right protective equipment. Surely, we should not be wearing and laundering our own uniforms? We get told by our management, who get guidance from the Public Health England, so should we just accept it? If it feels wrong, it usually is wrong. Would they come and work a shift here in their clothes and be happy washing it at home? Probably not.

There are not any showers for nurses at work. We bring this virus in to our homes on our uniforms, risking our children, our family and friends, not to mention ourselves. I feel filthy. I rush upstairs to shower while the uniform is boiling in the washing machine.

Scrubs are at a premium. There are not enough to go around.

I am upset over many things; I feel I can't do anything properly and feel useless. Everything we have ever known is different.

I would like to end this blog on a high note… The sun is shining, just in time for lockdown.

The varied case load is what I enjoy; the work can be stressful, but we have numerous algorithms, policies and procedures that we follow. These policies and procedures keep our patient safe and also gives us evidence-based approach to the treatment we give.

We are now seeing many COVID-19 patients. We now have two resuscitation bays in our emergency department: one side green (COVID free) and one side red (COVID-19). Anyone with a respiratory complaint is cohorted on the acute medical ward if they require admission. 

As an outreach nurse we spending a fair amount of time within the acute medical ward. This new cohort of patients seem to require higher concentration, they deteriorate quickly and need a close eye on.

We have electronic observations which has been a real game changer. We can now see all the patients in the hospital who are having a high NEWS score, we can track these patients and give the ward the support they need in caring for the deteriorating patient. Having this electronic system at this time has never been so crucial.

However, don’t be fooled by the number. One of the limitations of the NEWS2 charting is that the patient doesn’t score more for an increasing oxygen demand. The patient will score for being on oxygen whether that be one litre or 60%.

A patient (patient 1) can be scoring 4 on the NEWS chart and not be referred to outreach, as they do not ‘trigger’ until they get to 5. For example, in patient 1 – NEWS2 = 4

• Resps: 21
• Sats: 96%
• On 2 litres oxygen
• BP: 120/80
• HR: 60
• Aprexial

This patient is only on 2 litres of oxygen. This is relatively little oxygen, but they score for being on it as it is a sign of deterioration, but look at an example for patient 2:

• Resps: 21
• Sats: 96%
• On 15 litres oxygen
• BP: 120/80
• HR: 60
• Apyrexial

This NEWS2 score remains 4, despite patient 2 being on the maximum amount of oxygen staff can give on the wards.

During this crisis, I want to highlight that a patient with an increasing oxygen demand is escalated to either the ward doctors or the outreach team. Patients with COVID-19 deteriorate quickly on admission; they require increasing concentrations of oxygen over a short period of time.

Emergency intubation of COVID-19 positive patients on a ward is not safe. Staff need to wear full personal protective equipment (PPE) (not just a surgical mask and apron) to intubate as it is an aerosoled generating procedure. Our aim would be to get the patient to the intensive care ward first where the intubation is controlled with all the right PPE and only with a limited team to limit exposure.

Recognising and alerting the appropriate team that your patient has an increasing oxygen demand will reduce the risk of more people being exposed to this virus.

• What further work is needed to ensure that an increasing demand for oxygenation is added to the scoring of the NEWS chart?
• Is this a recognised issue for other healthcare professionals?
• What are other outreach teams doing to track patients with increasing oxygen demands? (tweet to @CCC_Outreach)

Demand in ITU/HDU beds is such that staff will be asked to work in areas that will stretch their knowledge and skills in support of the teams already working there. The issues with supply chains, normally an annoyance rather than a calamity, will now have a massive impact on the safety of staff as well as patients.

I'm sure people have seen the images of staff wearing personal protective equipment (PPE) for hours on end. In my own practice we have been pushing the first step of the donning process as being about staff welfare.

• Are you fit to wear the kit?
• Are you hydrated?
• Have you had a wee?

Simple three questions but poignant in the context of the Resuscitation Council UK (2020) guidance released this week on resuscitation and the need to ensure safety of staff over the needs of the patient and don correct PPE prior to resuscitation attempts.(1) 

Now put all of that – staff returning to frontline care after many years, the use of PPE for extended periods of time and changes in the way we care to ensure our safety – and ask yourself, how do you do that in a 12 hour shift, maybe the third one in a row, and without being able to get the normal shopping you would on the way home the night before?

We (healthcare in general) have a culture of putting the patient above everything else, including our health and wellbeing. The ‘Nurse bladder’ is legendary and often laughed about, especially when the surgeons get involved and one-upmanship becomes the banter, even though we are actually causing harm to ourselves.

Now add to that people who have had many leisure years or worked outside of clinical care for some time (not everyone re-joining have actually ‘retired’). IN the normal world they would have an induction, period of supernumerary time and supervised practice, and build up to the 12 hour working day. Will we really, in the time it will take to get these people onto the shop floor, be in a place to do this still? 

Before we even go into the whole returning to work issues we need to look at ourselves now. Caruso (2) reports that errors in 12 hours shifts are increased by as much as 28% in comparison to an 8 hour shift. This is before you add in the current issues. There has been many more studies showing the danger of the long day working. Indeed, this was part of the evidence that led to the changes in the junior doctor contracts in 2016. 

Changing back to the way we worked 25 years ago with a three-shift pattern may be a challenge. It will mean that nurses will need to really know their patients in a shorter time period but will be delivering safer care with less fatigue. It will mean that staff will have three handovers to go through but patients information will be updated at least three times a day instead of the normal two – presuming you are working in a 'work as done' environment and not the 'work as imagined'(3) world where by every patient has every part of their care documented immediately as it happens.

And it will mean that staff won't be able to work three long days for their primary employer and then go and work an additional two (or even more) days on a bank/ agency but they will be healthier and less likely to make mistakes. 

(It is worth noting, however, that long day working has enabled people to work as an HCP who wouldn’t otherwise be able to by reducing the amount they pay for childcare.)

With the evidence against long day working, why do we continue to insist we do it even though it puts us and our patients at risk?

Ultimately, changing back to a short shift system in the current climate could reduce the exposure we have to risk, and help support those returning to practice and support those of us currently in practice. 

In the immediate future there is still things we can do:

• If you have to wear PPE, ensure it is for the minimum amount of time and, after, you sit down, rest, rehydrate and refuel (4).
• If you're not OK, share with your team members so they can look out for you. 
• Plan your working day so that you know when you are going to take breaks and make sure everyone knows that this is your break time and you won't be dealing with any queries or questions during that time.

To aid the above, take your break outside of your immediate working environment. Lots of hospitals are opening welfare areas and there are still some that have staff areas.

And remember, we are no good to anyone if we are run down, broken and not able to function. 

References 

1. 3. Resuscitation Council UK (2019). Resuscitation of COVID 19 patients in hospital. Version 1. 2000.

2. Caruso C. Negative effects of shift work and long work hours. Rehabilitation Nursing 2013.

3. Hollnagel E, Braithwaite J, Wears RL. Delivering Resilient Health Care. Routledge. Oxon. 2019

4. Royal College of Nursing (2018) Rest Rehydrate Refuel. Accessed 22nd March 2020.

We hadn't thought the panic buying would start so quickly, or last so long. Toilet paper was a surprise. We hadn't bought any extra of that, so that was an issue, but our daughter managed to find some for us.

We are used to working from home. We have done it off and on for over a decade, so this situation is not new for us. We are tech savvy and able to use digital tools to meet our work needs. However, as freelancers, we have been hit hard by work just being cancelled and having much less to do than normal. Less money coming in too, soon.

The hardest thing of all has been that while we want to heed the Government's call to stay at home as reasonably high-risk individuals, we cannot book any food deliveries. Tesco, Ocado and Morrisons have no slots available at all. Thankfully we had two already booked with Tesco before the end of this month. After that, the food will start to run out here. With rationing etc already in place, our family who do visit the shops cannot buy extra for us.

At some point, regardless of the risk, we may have to leave the house. Wish us luck!!

But then Sandy's husband became ill and as she has been exposed to whatever her husband has, she has to now self-isolate at home with her husband.

Mark has had no helper now for 7 days. Mark has access to the US government assistant programme, but unfortunately there are no other aids available right now. So we are trying to get him home as soon as possible, but we can’t until he is symptom free. I am getting ready to jump on a plane. Being isolated and without an aid has caused him periods of considerable paranoia and anxiety.

Disabled people at home who rely on home healthcare are now at risk of no help. Fortunately Mark is very good at ordering out food for delivery and is able to walk with his walker to the pharmacy for his medication, but I worry about all the other disabled people who may inadvertently get abandoned in this pandemic due to low workforce.

*Names have been changed in this blog to ensure confidentiality.