Claire Cox

In this blog, Claire discusses the use of NEWS2 in coronavirus patients and the importance of recognising, tracking and alerting the appropriate team that your patient has an increasing oxygen demand to ensure that the risk of more people being exposed to the virus is minimal. I have just finished a stint of four long days working as an outreach nurse. Many of our staff are self-isolating. As outreach nurses, we come into contact with many different types of patient on a daily basis. We could be seeing a surgical patient with sepsis to a pre-eclamptic lady on maternity, it just depends on who needs you. 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)

This video demonstrates how to perform an intubation safely on a patient with coronavirus.

This new guidance set out by the Department of Health and Social Care covers a variety of scenarios relating to care homes, staff, and providers who care for people in their own homes to ensure older people and those with pre-existing conditions and care needs who receive support are best protected. Elderly people and those with underlying health conditions are much more likely to develop serious complications. Anyone who is suspected of having COVID-19, with a new continuous cough or high temperature, should not visit care homes or people receiving home care, and should self-isolate at home. People receiving care will be isolated in their rooms if they have symptoms of coronavirus. To ensure they can continue to receive the care they require, care staff will use protective equipment to minimise the risk of transmission.  Building on existing strong local relationships, the NHS will work with care providers where necessary to make sure people have the best possible care and remain in the community. GPs have been asked to look at the possibilities of offering digital appointments to provide advice and guidance to patients and potentially their families. Councils have been told to map out all care and support plans to prioritise people who are at the highest risk and contact all registered providers in their local area to facilitate plans for mutual aid.

This webpage has been developed by 'Sam' a new nurse in the Intensive Treatment Unit (ITU). Here, you will find useful aide memoirs, practical tips and hints on how to get a head with nursing on the intensive treatment unit. ITU handover Bedside checklists Transducing arterial lines Arterial line sampling Bedside monitoring Observations Ventilation basics Activity sheet. About the author Sam is a registered nurse who works for a Trust on the South Coast of England

Resilience in the context of anaesthesia and intensive care medicine is the ability to manage the breadth, depth, intensity and chronicity of the demands of the work. The concept of resilience is often misunderstood: it is a dynamic, contextual process that goes beyond the narrow conceptions of individual ‘toughness’ that it can be reduced to. Resilience is important for those working in anaesthesia and intensive care medicine, and indeed staff throughout healthcare, as it is inevitable that difficult cases and situations will be encountered during our working lives. In addition, the way in which we respond to these events is critical to our own welfare and competence at work. This article is about accepting that our working lives are difficult, that this is a big part of the attraction of our work and that it is wise to look at ways in which both team and personal resilience can be improved.

This American Society for Reproductive Medicine (ASRM) guidance is in response to the coronavirus (COVID-19) global pandemic. Their goal is to provide practices with recommendations that guard the health and safety of their patients and staff, and recognise our social responsibility, as an organisation and as a community of providers and experts, to comply with national public health recommendations. This guidance recommends the following: Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations (IUIs), in vitro fertilisation (IVF) including retrievals and frozen embryo transfers, as well as non-urgent gamete cryopreservation. Strongly consider cancellation of all embryo transfers whether fresh or frozen. Continue to care for patients who are currently “in-cycle” or who require urgent stimulation and cryopreservation. Suspend elective surgeries and non-urgent diagnostic procedures. Minimise in-person interactions and increase utilisation of telehealth. Note: This guidance will be revisited periodically as the pandemic evolves, but no later than March 30, 2020, with the aim of resuming usual patient care as soon and as safely as possible.

This is an easy to understand guide for people with learning disabilities who might be admitted to hospital with COVID-19. The author, Georgia, is a Speech & Language Therapist at Northants Healthcare.

This is an easy to understand infographic about correct PPE to wear during the Coronavirus crisis.

Novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 threatens healthcare resources throughout the world. This is particularly true for the patients who develop moderate to severe respiratory failure and require oxygen supplementation devices such as high-flow nasal cannula (HFNC). The HFNC uses humidification to allow the delivery of up to 100% oxygen at flow rates of up to 60 Lmin-1 ; however, there is a concern this may aerosolize respiratory tract pathogens. This report states that patient requiring HFNC are at least used in single occupancy rooms or negative pressure airborne isolation rooms. Healthcare workers caring for those using HFNC should be wearing full airborne personal protective equipment (i.e., N95 mask or equivalent, gown, gloves, goggles, hair covers, and face shield or hoods).

This blog was intended to give insights into what it is like working during this crisis on the frontline. I was going to explain what I see day to day, the stress that healthcare workers are under, the situation with personal protective equipment (PPE), the pressure on intensive care unit (ICU) beds and the ward. But unfortunately it's not that simple... Going to work for 12 hours, perhaps not having a break, perhaps not peeing for over 8 hours and being put in challenging situations on a daily basis is pretty much the norm for many workers on the frontline ANY day of the year, despite COVID-19. But now we have the pressure of adhering to guidance that keeps changing, confusion on who to test, who to 'barrier nurse', with lack of PPE in some areas. Staff are frightened. Frightened that they will bring coronavirus home to their families, frightened that they will become ill and frightened of the things they will witness in the coming months. Currently there is a petition calling for frontline NHS staff to be tested. We would then know who has the infection, keep them isolated so not to infect the vulnerable. In my hospital it’s taking five days to get a test result back. During those five days, patients are being barrier nursed. Barrier nursing ‘usually’ is a straightforward procedure and one nurse can look after a patient with relative ease. However, when barrier nursing a COVID-19 infected patient who is on non-invasive ventilation or aerosol therapies, it is much more disruptive. It can take two nurses to care for that patient, as ‘donning and doffing’ PPE is time-consuming and risky. The second nurse will act as a ‘runner’, collecting equipment, medication, linen – anything the patient and nurse need. The nurse will also need to take breaks separately to the rest of the team, leaving them feeling isolated. I know the Trust I work in has purchased point-of-care testing for coronavirus, but this won’t be up and running for two weeks. After a 12-hour shift, healthcare workers would then shower (if you are lucky), change their clothes and go home. Simple? No, we are not robots. We are human. We don’t go home, have dinner, have a full night’s sleep and start the next day. We have stuff going on outside work. We carry these stresses with us when we come into work; it affects our ability to ‘do a good job’. Staff are often struggling with outside stressors: divorce, moving house, child care, money and health – mental and physical. These stresses have not gone away since COVID 19 turned up. There are now new stressors in town which are affecting healthcare workers ability to stay focussed and to ‘do a good job’. These stressors are HUGE. Yesterday, the Government stated that they would help businesses with ‘what ever is needed’. That’s great but a loan won’t help in the long run. My husband owns a small business. He is a sculptor and makes small-scale sculptures for the garden and home. He employs six artists. These six people have made the business what it is today. They are talented and creative. One of them has just started a family, one has relocated from abroad to be here, and one has set up a new home. They have become my husband's ‘work family’; they are more than just employees. Yesterday, my husband went into work and told them that he was no longer able to pay them after April. Bigger companies have stopped ordering as there is no requirement for his product due to the restriction on gatherings of people. Smaller companies have stopped ordering as they are uncertain of what the future holds. Never have I seen my husband look so drained. Not only is he witnessing his business that he has worked so hard for collapsing before his eyes, he has had to let down the people that have helped to make it what it is. The mood in our house at the moment is sombre. I don’t want to add to my husband’s stress with my worries about work, so I keep quiet (this blog is helping). We have two boys,12 and 14. They are like labradors, they need lots of exercise. If the country is on lock down for three months they will be climbing the walls!! For anyone who has kids of this age, you know that they eat LOADS. As soon as the cupboards are restocked, they are emptied within 48 hours. I’m struggling to get healthy food for them as the shops seem to have nothing in them. After lock down, we shall know whose been stockpiling as they will emerge after three months overweight with very clean bums! Then there is the issue with childcare. If healthcare workers are to be on the frontline who is to look after the kids? If they are old enough and you leave them at home alone, how can you ensure they eat well, they study, they stay in? If they are young, who looks after them? Grandparents are now not the go-to option. This virus has affected everyone in multiple ways on multiple levels. No, this blog isn’t just about healthcare – it’s about being human. There will be many of us out there with stresses you are unaware of. Please, be kind. Call for action: Please send in any practical tips for barrier nursing patients and advice for staff well-being during this time. Join the conversation taking place on the hub.

This video has been produced by the staff at Guy's and St Thomas' Hospital NHS Foundation Trust. It demonstrates how to prone an intensive care patient. If proning a patient with COVID-19, full personal protective equipment (PPE) will be required by all staff.

Information governance is all about how to manage and share information appropriately. During these uncertain times, and with staff self isolating as well as patients, NHS X has advice for doing things differently. We will need to work in different ways from usual and the focus should be what information you share and who you share it with, rather than how you share it. The following advice sets out some of the tools that you can use to support individual care, share information and communicate with colleagues during this time. This includes communications tools where data is stored outside of the UK. This advice is endorsed by the Information Commissioner’s Office, the National Data Guardian and NHS Digital.

This guide contains advice and information about intensive care. It tells you how critical illness may be treated and what recovery may be like. Not every patient will experience all of these things, but they are more likely to if they have been in intensive care for more than a few days. Most of this guide is written for patients but there is a section specifically for relatives and visitors. By reading the guide, relatives will learn what a patient's recovery may involve and it will give them the answers to some of the questions they may have.

This short video by Gold Coast Health Australia demonstrates how to put on and take off personal protective equipment (PPE) when caring for a patient with COVID-19.

In this blog, Joanne Hughes, founder of Mother's Instinct and hub topic leader,  gives her response to the recent news that childrens' deaths at Great Ormond Street Hospital (GOSH) have not been investigated properly. Amid claims GOSH put reputation above patient care, former health secretary, Jeremy Hunt, urged it to consider a possible "profound cultural problem". Joanne's daughter, Jasmine, died in 2011 following failures in her care. Soon after Joanne set up Mother’s Instinct with the ambition to provide a source of support specifically for families whose children die following medical error, and a platform to share their stories and experiences for learning to improve patient safety for children, patient engagement in patient safety, and care of avoidably bereaved parents.

Professor Karol Sikora, in this video on Medscape, talks about the impact of the coronavirus pandemic on cancer care globally. Karl is a Professor of Cancer Medicine and Founding Dean, University of Buckingham Medical School; Consultant Oncologist; Harley Street Cancer Centre, London.

Coronavirus disease 2019 (COVID-19), caused by the COVID-19 virus, was first detected in Wuhan, China, in December 2019. On 30 January 2020, the WHO Director-General declared that the current outbreak constituted a public health emergency of international concern.  This document summarises WHO’s recommendations for the rational use of personal protective equipment (PPE) in healthcare and community settings, as well as during the handling of cargo; in this context, PPE includes gloves, medical masks, goggles or a face shield, and gowns, as well as for specific procedures, respirators (i.e., N95 or FFP2 standard or equivalent) and aprons. This document is intended for those who are involved in distributing and managing PPE, as well as public health authorities and individuals in healthcare and community settings, and it aims to provide information about when PPE use is most appropriate. 

I am going to write a series of blogs about my situation: what I'm seeing, my thoughts and my fears on the coronavirus, personally and professionally. I am a critical care outreach nurse one day a week and for the rest of the time I work non-clinically for the charity Patient Safety Learning.  My personal situation will not be unlike many. I have worries just like you – money, job, health, kids, elderly relatives (my parents will kill me for saying that!), food… It is important to capture our stories, no matter who you are or what you do. The impact of the coronavirus is widespread. It is affecting our daily lives and our future. Difficult to know where to start with this blog. Like the rest of the world, I’m anxious. We don’t know what is happening, we have not experienced anything like this before. When COVID-19 first arrived in late February (it felt like it snuck up on us, but I’m not sure that is the case), there was talk about some people having to work from home. This really suited me as I could easily do this in my role at Patient Safety Learning and it would mean I would be around more for my two boys. My boys are 12 and 14. Trying to parent boys of this age I find challenging at present. They seem to need me more than ever. I try to be a good parent, but usually feel guilty about letting them on the Xbox too long, feeding them chips more than once a week or not always knowing where they are or who they are with, especially if I am at work. I have normal parenting worries of bringing up teenagers. They are still at school today. How long that will last, I don’t know. The school has already set up online work for them and checked we all have internet access. My parents have said they will look after them if this is the case, so I can still go to work. The boys are delighted this will be happening at some point and can’t really see the long-term implications. If the Xbox doesn’t go down like it did last night – they should be fine. My parents are not old – in their 60s. Dad has a bad chest so I don’t want him to be put at any risk of catching the virus. With me going in and out of the hospital, I will be like a super spreader. I have told them to stay indoors and I won’t see them for a few months. I call them three times a day to keep a check on them. I think they think I’m mad. I’m just worried. As a nurse, my financial situation is stable. Working for the NHS is amazing; paid sick leave up to 6 months, great holiday entitlement and the likelihood of being made redundant in a clinical role is slim. I appreciate this ‘bubble’ that I work in. Yes, I’m usually skint at the end of the month, but I know I can work extra if needed and I will be paid at the end of the month – without fail. My husband on the other hand is different. He is self-employed. He employs six people. He has already had to lay one person off at the end of last week. Today he is giving the warning shot that they are all at risk of losing their jobs by the end of April. He has bills and wages to pay, funds are due to run out at the end of the month. My husband said to me last night that he feels that he has failed. He hasn’t – this is not his fault or anyone else’s fault. This is unprecedented. The mental health of everyone is at high risk here. It is affecting everyone in different ways. The mental health charities and services will be in demand – they are also under-resourced and overstretched as it is. My clinical background is cardiology, intensive care and critical care outreach. My skills are needed in the hospital at present. I want to help where I can. But I need to be at home with the kids, I need to be supportive of my husband who is going through a turbulent and worrying time with his business, I also feel pressure to help out clinically. My colleagues are going to work. Staff who shouldn’t even be going into work; many I know who have just finished chemotherapy, are immunosuppressed and who have underlying health problems. Healthcare workers are not immune, they are normal people too. We had a discussion at home this weekend. I shall work extra shifts at the hospital. Luckily my boss at Patient Safety Learning is understanding and is in full support. If I am honest – I am very nervous to what I may witness in the coming weeks/months. I have worked in difficult situations in the past. Working in a field giving aid to 30,000 migrants on the Greek/Macedonian border was what I thought hell was. I saw pain and suffering on a grand scale. However, this was relatively short lived and confined to certain groups of people. This is not. This is affecting everyone, no matter how much money you have, the colour of your skin, nationality or religion and there is nothing you can do about it. We do not have enough resources to care for the amount of people who will need it. Working on the intensive care unit, you are protected. You have your patients who have access to everything they need – doctors, nurses, drug and equipment. If we are to start rationing resources or restrict who will receive treatment and who doesn’t, it will make caring for patients on the wards unbearable. I have been called in to work clinically on Thursday. Nurses have had to self-isolate for different reasons. I have never felt scared to go to work before. I don’t think I am prepared to watch people die from this virus. I shall blog an update later this week. I would urge anyone to write their account on how they are feeling or what it is like to be you, whether you work in a care home, in theatres, in primary care or as a support worker, or even if you have been affected by the virus – your stories may help others and may help to inform future care and policy if this was to ever happen again. We all need to highlight what’s happening now that needs to be attended to. Join the conversation in our Community area.

A growing number of studies have focused on 2019 novel coronavirus disease (COVID-19) since its outbreak, but few data are available on epidemiological features and transmission patterns of children with COVID-19. This study, published in Pediatrics journal, examined the epidemiological characteristics and transmission patterns of 2143 paediatric patients with COVID-19, using a retrospective analytical approach.  The authors found that children at all ages were susceptible to COVID-19, but no significant gender difference was found. Clinical manifestations of paediatric patients were generally less severe than those of adults’ patients. However, young children, particularly infants, were vulnerable to 2019-nCoV infection.

This document outlines the infection prevention and control advice for healthcare workers involved in receiving, assessing and caring for patients who are a possible or confirmed case of COVID-19. It is based on the best evidence available from previous pandemic and interpandemic periods and focuses on the infection prevention and control aspects of this disease only, recognising that a preparedness plan will consider other counter measures. The infection prevention and control advice in this document is considered good practice in response to this COVID-19 pandemic. NB: The emerging evidence base on COVID-19 is rapidly evolving. Further updates may be made to this guidance as new detail or evidence emerges. 

Guidance from the Ministry of Justice and Her Majesty’s Prison and Probation Service about visiting prisons during the coronavirus outbreak.

The global impact of COVID-19 has been profound, and the public health threat it represents is the most serious seen in a respiratory virus since the 1918 H1N1 influenza pandemic. Ferguson et al. present the results of epidemiological modelling which has informed policymaking in the UK and other countries in recent weeks. In the absence of a COVID-19 vaccine, they assess the potential role of a number of public health measures – so-called non-pharmaceutical interventions (NPIs) – aimed at reducing contact rates in the population and thereby reducing transmission of the virus. In the results presented Imperial, apply a previously published microsimulation model to two countries: the UK (Great Britain specifically) and the US. They conclude that the effectiveness of any one intervention in isolation is likely to be limited, requiring multiple interventions to be combined to have a substantial impact on transmission.