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Key findings 45% of respondents have seen a permanent increase in the critical care capacity of their directorates. However, when asked if they consider any increase in capacity to be adequately staffed only 18% of respondents agreed. 60% of respondents reported that their units are still attempting to follow the Guidelines for the Provision of Intensive Care Services (GPICS) but 54% of respondents have seen some relaxation of those standards including to their medical staffing. 80% of respondents increased their working hours, and 71% report covering sick consultant colleagues. Future uncertainties affect the wellbeing of the Faculty’s fellows and members. How hospital structures support those working in critical care is vitally important for both recruitment and retention. 88% of respondents had leave cancelled. Work/life balance is extremely important. Whilst the vast majority of respondents were happy to deliver the needed increase in work in the first wave, to do this over subsequent waves of the pandemic becomes increasingly difficult for individuals and their family. Supporting professional activities and agreed job plans will be even more important in subsequent COVID-19 waves. Faculty fellows and members understood the impact the first wave of COVID-19 had on non-critical care staff, and hugely appreciated their response to the crisis. The flexible increase in staffing was so important for care, although the drop in GPICS standards underlines the need to increase the underlying critical care capacity, and the multi-disciplinary workforce. Key recommendations GPICS standards exist for reasons of best care, safety and governance. Units should be attempting to adhere to them or working towards achieving them. Inability to meet GPICS standards needs to be brought to the attention of management structures within hospitals and plans for addressing deficiencies identified and implemented. Supporting and maintaining the wellbeing of critical care staff is vitally important. Not only for recruitment by attracting multi-disciplinary team members in, but also for their retention in the specialty. Staff must not be taken for granted and listening to the voices from the frontline is only the start of this process. Enhanced Care recommendations, written and promoted by the Faculty, will allow for greater flexibility in future responses to surges in demand as well as safer care for those needing a higher level of care. Critical Care Directorates should make the case widely within their hospitals for enhanced surgical and medical care.

In this study from Timmel et al., CUSP was implemented beginning in February 2008 on an 18-bed surgical floor at an academic medical center to improve patient safety, nurse/physician collaboration, and safety on the unit. This unit admits three to six patients per day from up to eight clinical services. Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on a surgical inpatient unit after implementing a safety programme. As part of the CUSP process, staff described safety hazards and then as a team designed and implemented several interventions. CUSP is sufficiently structured to provide a strategy for health care organizations to improve culture and learn from mistakes, yet is flexible enough for units to focus on risks that they perceive as most important, given their context. Broad use of this program throughout health systems could arguably produce substantial improvements in patient safety.

Key takeaways Presentation weeks and/or months after ICU discharge Physical and mental tolls of critical illness and care Beware of the possible warning signs, which may include: muscle weakness or problems with balance, problems with thinking and memory, severe anxiety, depression and nightmares The medical community expects to see a high number of PICS cases among COVID-19 survivors due to the increasing number of patients receiving critical care.

Actions required Primary actions to be completed by 7 October 2020: Identify and locate affected devices in your organisation. Identify alternative ventilators available on site. If no suitable alternative available, and capacity is an issue currently or expected imminently, follow protocol for resource shortage escalation set out by your local governance. Train all relevant staff on alternative ventilators and ensure training records are up to date. When actions 1–4 are complete, remove affected V60s from use and quarantine until repaired by the manufacturer. Place the alternative devices into service in place of the affected V60s. You may continue to use affected V60s if there is a risk of severe patient harm due to lack of ventilator availability. A thorough risk assessment must be completed, and additional monitoring must be used. A backup form of ventilation must be available at all times. Secondary action to be completed by 23 December 2020: 8. Review procurement and stock policies to ensure you are not reliant on one manufacturer or model of ventilator.

The outcome is that the RCP released a statement on its website relating to revised guidance on the use of early warning scores for COVID-19 inpatients. The RCP suggest that all staff should be aware that any increase in oxygen requirements should be an indicator of clinical deterioration as the early warning score might not significantly increase.

This guide does not override the responsibility of the healthcare provider to use professional judgement and make decisions appropriate to the circumstances of each patient in consultation with the patient and/or guardian. Whilst this document is aimed primarily at staff working in secondary care, much of the material is applicable to primary care (GPs, community care homes and carers). It is designed to help you provide consistent, high quality care for your patients with a tracheostomy.

This easy reference guide has been produced because: Some aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable. This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive. However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients. This is version 2 of the aide memoire, which includes additional advice on situations where providers can continue to safely use more complex local polices. Other changes were minor refinements of language and use of capital letters to emphasise application to checks before first use.

It's been a busy few months to say the least. Preparing for the pandemic, sourcing correct personal protective equipment (PPE), redeploying staff, acquiring new staff, making ventilators, redesigning how we work around the constraints, writing new policies, new guidance, surge plans, and then the complex part… caring for patients. If I am honest, when this all started it felt exciting. Adrenaline was high, motivation was high, we felt somewhat ready. There was a sense of real comradeship. It felt like we were all working for one purpose; to safely care for any patient that presented to us in hospital. We were a little behind London by about 2–3 weeks, so we could watch from afar on how they were coping, what they were seeing and adapting our plans as they changed theirs. Communication through the ITU networks was crucial. Clinical work has been difficult at times. The initial confusion on what the right PPE to wear for each area added to the stress of hearing that our colleagues in other places were dying through lack of PPE. The early days for me were emotionally draining. However, this new way of dressing and level of precaution is now a way of life for us. I have come to terms that I am working in a high-risk area and I may become unwell, but following guidance and being fastidious with donning and doffing helps with ‘controlling’ my anxieties in catching the virus. Some parts of the hospital remained quiet. Staff had been redeployed, elective surgery cancelled and the flow of patients in the emergency department (ED) almost stopped. I remember walking through ED and thinking: where are the people who have had strokes? Have people stopped having heart attacks? Are perforated bowels not happening anymore? The corridor in ED is usually full. Ambulances queuing up outside, but for a good few weeks the ambulance bays were deserted. The news says over and over again "we must not overwhelm the NHS". I always have a chuckle to myself as the NHS has been overwhelmed for years, and each year it gets more overwhelmed but little is done to prevent winter surges, although it's not just winter. The surge is like a huge tidal wave that we almost meet the crest of, but never get there, and emerge out the other side. I sit in the early morning ITU meeting. We discuss any problems overnight, clinical issues, staffing and beds. We have seen a steady decline in the number of ITU patients with COVID over the last week or so. The number of beds free for COVID patients were plentiful. We have enough ventilators and staff for them. This is encouraging news. I take a sigh, thinking we may have overcome the peak. In the next breath, the consultant states that we don’t have any non COVID ITU beds. We have already spread over four different areas and are utilising over 50 staff to man these beds (usually we have 25 staff). So that’s where the perforated bowels, heart attacks and strokes are. The patients we are caring for had stayed at home too long. So long, that they now have poorer outcomes and complications from their initial complaint. These patients are sick. Some of the nurses who are looking after them are redeployed from other areas; these nurses have ITU experience, but have moved to other roles within the hospital. This wasn’t what they had signed up for. They were signed up for the surge of COVID positive patients. I’m not sure how they feel about this. As the hospital is ‘quiet’ and surgical beds are left empty, there is a mention of starting some elective surgery. This would be great. It would improve patient outcomes, patients wouldn’t have to wait too long, so long that they might die as a consequence. However, we don’t have the capacity. We have no high dependency/ITU beds or nurses to recover them. We would also have to give back the nurses and the doctors we have borrowed from the surgical wards and outpatients to staff ‘work as normal’, depleting our staff numbers further. Add to the fact that lockdown has been lifted ever so slightly, the public are confused, I’m confused. With confusion will come complacency, with complacency will come transmission of the virus and we will end up with a second peak. If we end up with a second peak on top of an already stretched ITU and reduced staffing due to the secondary impact on non COVID care, the NHS will be overwhelmed. This time we will topple off that tidal wave. It’s a viscious cycle that I’m not sure how we can reverse. My plea, however, is to ensure we transition out of this weird world we have found ourselves in together. We usually look for guidance from NHS England/Improvement, but no one knows how best to do this. The people who will figure this out is you. If your Trust is doing something that is working to get out of this difficult situation, please tell others. We are all riding the same storm but in different boats. I would say that I am looking forward to ‘business as usual’ – but I can’t bare that expression. Now would be a great time to redesign our services to meet demand, to involve patients and families in the redesign – to suit their needs. We have closer relationships now with community care, social care and primary care, we have an engaged public all wanting to play their part. Surely now is the time we can plan for what the future could look like together? The Government has announced that Ministers are to set up a ‘dedicated team’ to aid NHS recovery. We need to ensure that patient and staff safety is a core purpose of that team’s remit and the redesign of health and social care. Would you be interested in being on our panel for our next Patient Safety Learning webinar on transitioning into the new normal? If so, please leave a comment below.