Claire Cox

This resource includes: What is medicines management? The right medicine for the right patient and the right time Becoming an independent prescriber Competencies and maintaining competence Specialist prescribing Delegation Unregistered staff and social care Administration Prescribing and administration Transcribing Nursing associates and medicines management Summary of available guidance

Background: Acute kidney injury (AKI) in critically ill patients is multifactorial. There is little reliable UK data on the incidence and outcomes of patients with COVID-19 and AKI outside the ICU. At this stage we do not have a full understanding of the aetiology of AKI in COVID-19 and the pathogenic role of systemic inflammation, hypovolaemia or other COVID-19 related pathology (such as thrombotic microangiopathy) in its genesis. Volume status is critical in reducing the incidence of AKI but the balance between respiratory and kidney function can be challenging. Preventing avoidable AKI should be a key goal of the management of hospitalised patients, to reduce demand for renal replacement therapy (RRT). AKI should be promptly recognised and managed appropriately, within the limits of our current understanding. AKI confers an adverse risk of mortality and its presence reflects underlying morbidity and current illness severity. The presence of AKI should inform assessments of prognosis and in some cases the appropriateness of escalation of care. It is critical that we build on existing processes and knowledge and carry on doing the things we currently do well.

Key points: Student paramedic practice, especially in the placement environment, mirrors human factors seen post registration, but also has its own unique set which require further research. The relationship between student and mentoring paramedics is a unique and important human factor in student development. Many clinicians may not feel prepared or willing to undertake a mentorship role. More training and support for mentoring paramedics would be of benefit. Emotional stresses faced by students when they initially encounter emotive aspects of the placement environment should be recoginised. Institutions and placement providers should encourage students to identify and practise coping mechanisms as well as offer support. Placement environments vary nationally and globally, and due to the nature of the job, it is difficult to nurture confident students and clinicians. However, adaptions could be made to reduce stresses on both parties.

When driving to work at the beginning of the pandemic, I felt a sense of worry and apprehension of what I would be faced with. As a critical care outreach nurse I never know what I may be faced with, but this has never bothered me. However, during the pandemic it did bother me. I worried how I could do my job; would I get sick and how would I navigate my way through the new ways of working? Seeing the brightly coloured rainbows in people’s windows gave me some hope. I knew that the public were thinking of us; they knew the risks we were putting ourselves at and our families. For a time, I felt special. It sounds pathetic, I know. For a time, I felt valued. Valued by the public, valued by the trust I work for and valued by politicians. As NHS staff we had priority shopping, we had discounts from big stores, we had free parking, we had donations of food every day while we were at work, we were donated hand creams and toiletries. School children drew us pictures to put on the walls of our staff room saying ”thank you”. What made me feel valued more than anything was staff wellbeing being at the forefront. Extra staff were redeployed to work on the ITU, we were made sure we had all our breaks and we were made to feel that each and every one of us counted. Relatives of patients wrote and expressed their gratitude, even if they were unable to visit their dying family – they were truly grateful to us. The ITU where I work received so many beautifully written letters and cards. We pinned every one onto the wall so we were reminded that we were shining bright despite the darkness. Then there was the Thursday clap. Personally, I thought this was an odd thing to do, but it seemed to bring people together and have a shared purpose – even if it was for a fleeting 5 minutes a week. When I think back at those months, it seems like a lifetime ago. Eve Mitchell’s recent blog on the hub highlighted that care homes are receiving complaint letters and some are even receiving threats of litigation. “Not enough PPE”, “lack of care given to my family member”, “my family member was neglected during the pandemic” – frustration and anger are palpable. Frustration and anger because families were unable to visit their relatives in their last days, frustration and anger that these precious moments have been denied from them. If it were my mum or dad would I feel the same? Of course I would. I would be the loudest voice there. Is it the fault of the care home? Should they be vilified for the protection of their residents? And now it’s the turn of the hospitals. We now have over a million people waiting on lists for operations, procedures, appointments. Some have already waited months before the pandemic started. Some have already died as a result of not having surgery at the right time. Patients have received surgery and treatment late and this has led to complications and a longer hospital stay – which then increases their mortality. At some point the gratitude from the public will turn to anger and frustration, as it has with the care homes. Would I be angry if my mum was waiting for an operation and died as a result of a prolonged wait? Yes I would. It is a natural response to blame the very people who should have helped – the NHS staff. I now drive to work and see faded rainbows in windows, I will be paying for parking again in the next few weeks, the donations of food have dried up, staff are back at ‘normal’ levels and I am back to having no breaks some days, not to mention that nurses were not included in the recent pay rise. I feel that we have served our purpose. ‘Thanks very much – now get back to normal, sort the waiting lists out and work harder to make sure it happens’. I don’t envy our senior leaders in acute Trusts. They are stuck in the middle of the Department of Health and Social Care and NHS England who are trying to fathom out a strategy to get the waiting lists down, and support frontline staff who are exhausted and a frustrated public that may erupt at any moment. Frontline workers have been through it the last few months. Navigating our way through complaints and litigation and an angry public who feel that they are not receiving the care that they expect in the coming months fills me with dread. We are not equipped. Faded rainbows – is this a representation of the fading support we are receiving in the NHS?

The first presentation draws on a recent National Institute for Health Research (NIHR) funded mixed-methods evaluation of the translation into practice of several ‘post-Francis’ policies that have aimed to improve openness in the NHS, and identifies key conditions necessary for policies to make sustainable impact on culture and behaviour. The second presentation reflects on material from a forthcoming book which will offer unfiltered accounts from patients, carers and healthcare professionals about their good and bad experiences of how care is organised, from birth up to the end of life. Their testimonies indicate the salience of kindness and attentiveness combined with efficiency and competence. Finally, the context for a culture of openness and for patient-centred services will be presented, alongside the development of a culture change programme which is being used in 70 Trusts in England. Significant and unacceptable variations in the availability of high quality care and in staff wellbeing persist across the NHS and social care, exemplified by very different COVID-19 experiences across the sector. How far does this kind of research on culture and these kinds of programme interventions help us to gain whole system traction in this important area of laying the conditions for reliably compassionate patient care? How can positive cultures and new working practices that have developed during the COVID-19 pandemic be sustained?

This leaflet includes patient information on: why is patient safety important how you can help your medicine recognising acute illness what happens if your Early Warning Score increases? what should relatives or friends do if they are worried that your health is worsening or not improving? blood clots safe surgery infections falls prevention advice preventing pressure ulcers.