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Steph O'Donohue

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About Steph O'Donohue

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  • First name
    Stephanie
  • Last name
    O'Donohue
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    United Kingdom

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  • About me
    Copywriter in the healthcare industry.

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  1. Community Post
    From the Head of ICU at the Royal Free (shared via Facebook): “Dear All, I have just finished a very useful ICU / NHS Nightingale teleconference, the aim of which was to consolidate experiences about CV19 and how best to manage the disease. I have provided a summary below. Please understand that the information is experience, not evidence. I think it highlights a number of areas that we need to discuss URGENTLY as a group. The take home message is that advice given at the beginning of this journey needs to be adapted as we learn more about CV19. The other important thing to begin to understand is that this disease has distinct phases and treatment will differ as patients move through these phases. The call had about 80 people on it, most listening. There were about ten “experts” invited to speak, from high volume centres. I represented our site. Others included Georges, GSST & Brompton. Ventilation - Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness. - Avoid spontaneous ventilation early in ICU admission as also may be harmful. - There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space. - Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related. - Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation. - Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT. - Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier. - Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting. - Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days. - Generally people are using humidified circuits with HMEs. - A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily. - Leak test before extubation is crucial, others are also seeing airway swelling. - Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high. My conclusions from this are: - Less aggressive PEEP strategy at the beginning of the disease and go straight for proning. - Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky. - An extubation protocol is needed immediately. - We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease. Fluid balance - All centres agreed that we are getting this wrong. - Most patients come to ICU after a few days of illness where their temp was 38-40 and they were hyperventilating i.e. severely dehydrated. - High rates of AKI being caused by over zealous driving with frusemide, leading to unnecessary CVVHF. - Hypovolaemia leads to poor pulmonary perfusion and increased dead space. - Centres echo’ing their patients are seeing a lot of RV dysfunction without raised PA pressure. - Many have improved oliguria by dropping the PEEP i.e. these patients are really hypovolaemic. [On nights I have observed many of our patients with a zero fluid balance and temperature of 39 i.e. they will be 2-3 litres negative in reality.] - Most centres are therefore now backing off of strict zero balance, particularly in hyperpyrexia. They are moving more towards avoidance of large positive fluid balance. - Lung ‘leak’ not as prominent in this disease as classic ARDS My conclusions from this are: - Avoid hypovolaemia as it will impede gas exchange and cause AKI. Progression to CVVHF increases mortality. - Avoid hypervolaemia - How we achieve this is difficult, but the frusemide and noradrenaline cocktail needs to be carefully tailored, especially in pyrexial patients. - Echo patients to understand their volume status. Renal - Higher than predicted need for CVVHF - ? Due to excess hypovolaemia. - Microthrombi in kidneys probably also contributing to AKI. - CVVHF circuits clot frequently. Georges and Kings now fully anticoagulant the patient (rather than the circuit) as it is the only way they can prevent this. One centre using full dose LMWH as they have run out of pumps. - Kings now beginning acute peritoneal dialysis as running out of CVVHF machines. My conclusions from this are: - Aggressive anticoagulant strategy required for CVVHF, potentially systemic. - If we run out of machines, PD may / may not help (our previous experiences with it are not great, but I have no alternative other than using CVVHF like intermittent dialysis and sharing machines) Workforce - A ’tactical commander’ is essential on every shift, who is not directly responsible the care of ICU patients. - Most centres now getting towards 1:6 nursing ratio with high level of support workers on ICU. - Training has largely fallen by the wayside as it is too large a task. People are being trained on the job. My conclusions from this are: - On call consultant to coordinate but not be responsible for patients (as is the model we have now adopted). - We need one support worker per patient. Other centres are using everyone they have. From med students to dental hygienists. We are behind the curve ++ with this. Last time I was on a night shift, theatres were full of non-medical staff refusing to help ICU - this is unacceptable. There were some brief discussion about CPAP: - Proning patients on CPAP on the ward is very effective, I tried it the other day - worked wonders. - Prolonged use of CPAP may (I stress the word may) lead to patients being more systemically unwell when they get to ICU. - Considerable oxygen supply issues with old school CPAP systems. My conclusions from this are: - As per local guidelines, assess the effectiveness of CPAP after an hour, if it isn’t effective then bail out and consider intubation. - If effective, regular review is required. If at any point it is failing, bail out and consider ventilation. - Whilst we may have a shortage of ventilators, holding people indefinitely on CPAP may be short-sighted as it may be converting single organ failure into multiple organ failure. OK, that’s all I have. I will stress again that this is simply a summary of discussions, none of which are backed up by large, robust multi-centre RCTs. My conclusions after each section are nothing more than suggestions to be discussed. We need to adapt fast to what we learn about this disease and learn from our colleagues at other centre. We are all in this together and joined up thinking is required. Lastly, we desperately need to look at our own data to understand whether we are getting this right or not. Good luck, stay stay safe and be kind to one another. Dan Daniel Martin OBE Macintosh Professor of Anaesthesia Intensive Care Lead for High Consequence Infectious Diseases Royal Free Hospital London
  2. Community Post
    A Facebook follower, commented the following re emergency dental services and local responses...
  3. Community Post
    My mum has been losing weight for almost six months (unexplained). She is undergoing tests to see if she has a rare adrenal tumour. Due partly to how long the analysis takes for these tests, they have taken a long time. Her consultant appointment is due end of April - now to be done over the telephone. If they do discover it is the adrenal tumour, she would need further investigation to identify whether or not it is cancerous (usually not cancerous) and potentially an operation to remove it so she can recover (fairly good outcome stats). My concern is that if this appointment gets cancelled, she cannot afford to continue to lose more weight, she will literally waste away (she is only 7 stone something at the moment). Will she just be left to deteriorate?
  4. Content Article Comment
    Amazing blog...is everyone really being expected to bring their uniforms back to their family homes to wash? As a patient, I am so angry that our NHS heroes are feeling frightened unprotected and that they are failing in multiple areas of life, when they are actually holding everything together for the country.
  5. Content Article
    The Health and Social Care Select Committee is currently holding an inquiry to consider the preparedness of the UK to deal with the coronavirus pandemic. MPs will focus their discussion on measures to safeguard public health, options for containing the virus and how well prepared the NHS is to deal with a major outbreak. 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.
  6. Community Post
    Hi, these may be of interest/help... Mental health and well-being during coronavirus crisis (15 March 2020) WHO: Coping with stress during the 2019-nCoV outbreak
  7. Community Post
    This blog may be of interest to this thread too - Coronavirus means difficult, life-changing decisions for me and my cancer patients
  8. Community Post
    I'm being made more and more aware of this lately too. It led me to this very interesting blog site ...
  9. Community Post
    Not sure if this is the same one Helen, but there's a documentary with Stacey Dooley out tomorrow - she spends some time in a '136 unit' (designated place of safety). https://www.bbc.co.uk/programmes/p082bxzn
  10. Content Article
    I thought that as a copywriter and passionate advocate of clear and simple language, I was all too aware of the dangers of using jargon. During a health and safety training course, I was proved wrong... The facilitator, a community nurse, told us a story of when she was looking after patients who'd had knee replacements. She noticed very few were recovering at home as quickly as she might have expected. It wasn't until she unpicked the advice given to them and the language used that she found the answer. Language. Her patients had all been advised to elevate their leg. It turned out that many of her patients didn't know what it meant to 'elevate' their leg. And because of this, their recovery had been set back. This story really struck a chord with me because I would have happily used the word elevate in my writing without thinking twice. I was clearly not as aware as I had thought. This was an important example though. An example that highlights a direct impact on patient safety and care, and raises concerns about the more complex terminology often used by clinicians when talking to patients. So, it begs the question... if there is a simpler way of describing or saying something, then why don't clinicians do it? Maybe because it requires more words in a world where efficiency is crucial... 'keep your foot up on a stool or something like that'. Maybe it's difficult to switch from essential medical speak to less technical language so many times a day depending who you are speaking to? Maybe it's hard to remember that certain well-used words in their day-to-day lives are not common place elsewhere? Maybe, in some cases, it makes them feel powerful, respected, superior? Whatever the reason, surely the communication itself is pointless if ultimately the message is not being clearly communicated? As a writer, for me everything comes down to the key messages and key objectives. What do you want people to know? What do you want them to do? Often in healthcare, the motivation behind these questions is based on a desire to keep a patient safe. Having worked in the health industry for many years, I can't help but feel frustrated by the jargon often used by health and care professionals – verbally and on paper. I guess I just feel they are shooting themselves in the foot (perhaps they should consider elevating it...). I have watched passionate and conscientious staff work tirelessly to put patients at the heart of their practice. I do wonder if they have a second to even think about language on top of everything else. But I believe that using clear and simple language is key to keeping patients safe... which is surely their raison d'etre while at work. So what can we do about it? I would challenge teams to put themselves to the test. Why not bring a bell to your next team meeting and ask colleagues to ring it every time they hear a word that could be said more simply? To avoid tinnitus, it might be wise to start by using the bell for just five minutes. There are so many benefits to this exercise: It encourages an internal culture where colleagues are able to speak up if they don't feel something is made clear – to know that there will always be things others know that you don't, and vice versa. To celebrate those who assertively seek out clarification and shun any shame that can accompany lack of understanding. It helps people really start to develop an awareness of the words they use and to differentiate between professional speak and human speak. To know their audience and to adapt quickly when needed. Learning to use clearer language when writing or talking about health can only be a good thing. It will increase the chances of key messages being received and patients feeling informed and better equipped to take part in their care. In my experience, language can act very powerfully to either include or exclude people. In an industry where patient engagement is key to outcomes, surely it's time we ditched the jargon? Have you tried any exercises as a team to help improve communication, in order to improve patient safety?
  11. Content Article Comment
    Really interesting video, particularly when she speaks about how she felt that she was sometimes viewed as a 'difficult patient' while trying to contribute to her own safe care.
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