As new NHS Nightingale hospitals spring up across the country, Sally Williams hears how South West London Elective Orthopaedic Centre (SWLEOC), the UK’s largest NHS treatment centre for elective orthopaedic surgery, transformed into an ITU for COVID-19 patients in just seven days. Here’s what the centre’s Medical Director (and BOA member), Mr Vipul Patel, said in the week of 6th April 2020.
Published 16 April 2020
We had just seven days to prepare before we took our first COVID-19 patient. Our unit usually performs the largest volume of joint replacements in the UK, including hip and knee replacement surgery. That’s all on hold. We were instructed to stop all elective orthopaedic surgery on 18th March.
Initially we thought we’d provide emergency orthopaedic services and we ordered kit to enable us to deliver trauma care. But as our two hospitals began to be deluged with COVID-19 patients, we were told to get ready to take some of these patients.
We had to look at everything: environment, infrastructure, equipment, supply chains, manpower, training, pathways. It has been a huge learning experience for us. As an orthopaedic service, preventing infection in surgical wounds has always been top of our agenda. We needed to apply this knowledge to protecting healthcare workers whilst supporting our ITU colleagues to deliver the best possible care in the circumstances. We learnt from the experience in China, which helped us to adapt the physical space, including designating different zones and designing the pathway for staff to enter and exit whilst keeping them safe.
Repurposing existing facilities
Our unit has three floors; the first two floors each have a ward of 27 beds. There are five state-of-the-art operating theatres on the third floor. There’s a 17 bedded post anaesthetic unit (PACU), where patients go to recover after surgery. It has high dependency and critical care facilities and was designed to be a spacious area in which patients can be closely monitored.
This PACU has now been repurposed into an ITU. Currently, all 17 beds are occupied by patients with coronavirus. There are five further patients in the operating theatres. We don’t have enough ventilators, so we are using the machines anaesthetists use during surgery as ventilators.
One of the early challenges was around the oxygen supply. Treating more people requires a higher flow of oxygen. We were initially told it would take three weeks to install pipes big enough to support this. In the event, a team completed the job within three days. All three floors now have a higher flow oxygen supply, which means we can expand into these other areas if patient numbers increase.
Protecting staff from infection
We belong to a network of critical care across multiple hospitals. The network supports us to overcome challenges, such as providing additional ventilators. They can also provide doctors with the right skills to work in the ITU, together with experienced ITU nurses if we have staff shortages. One ITU nurse covers six to eight patients. Each patient is also assigned their own nurse; these nurses come from a range of clinical areas, including the operating theatres, wards and pre-assessment. Pharmacists, healthcare assistants, physiotherapists, porters, and domestic staff are also helping and supporting.
A team of senior clinicians, nurses and managers have worked together to facilitate the things that clinicians in the ITU need and to ensure that staff are protected. During the seven days of preparation, my orthopaedic surgeon colleagues (many of whom have academic roles) led intensive staff training sessions, to educate staff in COVID-19, how it spreads, how they can protect themselves, and what to do if they get symptoms.
We devised a pathway for staff before they enter the zone where patients with COVID-19 are cared for. The first-floor ward has been repurposed into an area for donning personal protective equipment (PPE). The donning area has been designed so that each piece of PPE is put on in a logical sequence. Senior clinicians take turns to observe staff in the donning areas when shifts change over to make sure they are putting on PPE properly. We have now trained administrative staff to do these observations morning and evening.
A rest area has been created on the first floor, where staff on shift can rest and eat. Everything is provided for staff so they don’t need to leave the building. Some local restaurants have been very generous in providing wonderful meals.
Several patient rooms have been converted into changing areas with showers, and staff are encouraged to shower at the end of each shift to clear the virus from their hair or skin. Staff already on shift or coming off shift are kept separate from those coming on to the next shift.
Constantly improving how we do things
We have implemented continuous quality improvement. We started doing staff surveys within a couple of days of going operational. Every time staff come off shift, they are asked to answer five or six simple questions, like “how safe did you feel” and “what could have been done better?” This, along with soft intelligence obtained by talking to clinicians during their handovers, enables us to introduce improvements at daily operational meetings.
Staff fed back that the FFP3 respiratory masks were uncomfortable and made them feel quite dehydrated. They asked for bottles of water, but this would have meant taking the masks off to drink. They asked for straws, but this wasn’t safe either. We now organise shifts so that everyone is encouraged to take a break every three hours. Staff are supplied with bottles of water before they go into the patient zone and encouraged to hydrate as much as they can.
Staff have said that they feel really well looked after. So much so that our team has been asked to advise the unit on our other hospital site how to improve their pathways to reassure staff they are safe.
Our academic colleagues have put together a protocol for collecting data from these patients that can be analysed to help improve care for patients in the future.
We have set ourselves some very simple goals. Our main priority is to protect staff and facilitate their work. For now, whilst elective orthopaedic surgery is on hold, my job is to be a trouble-shooter and problem-solver. I am privileged to be supported by great colleagues. Strong teamwork has made change happen and we’ve tried to respond as best we can to this unprecedented challenge.
As told to Sally Williams, Director, inQuisit Ltd. Sally is an experienced health services researcher and health policy analyst and is review manager for BOA Elective Care Reviews.
This article first appeared on The inQuisitor blog.