Intensive care unit, being on the frontline

 

Frontline workers are being applauded globally for continuing to work closely with confirmed cases of the coronavirus. Professor Carol Hodgson, FACP, and Dr Scott Bradley, physiotherapy team leaders at The Alfred Hospital ICU department in Melbourne, discuss  working in critical care during a pandemic. 

As COVID-19 began to impact hospital workers before spreading to the rest of the country—as early as January, following the news of the coronavirus from London and then New York—the Australian Department of Health and the federal government were planning for what was anticipated to be an overwhelming strain on hospital resources, particularly on ICU resources from infected patients.

Speaking about the steps the ICU staff at The Alfred Hospital took to prepare for the first wave of the virus at the beginning of the year, Scott Bradley says the first task was to plan for a massive increase in the number of patients requiring intensive care, and potentially the number of patients that might require ventilation.

‘Some health services sourced a number of ventilators,' Scott says. 'In Victoria we went from a capacity of around about 450–500 ICU beds to potential capacity of approximately 3000– 4000. Across Australia, the Department of Health was thinking about going up by 2000 beds to the 10,000 mark.

'So we were in the position of trying to plan for a massive increase in the number of beds.’

For The Alfred Hospital, specifically, this ‘meant going from our usual ICU patient number, which is about 50, to potentially having 300 ICU patients. So the first thing we had to decide: how are we going to do this, how are we going to plan for this?’ Scott says.

There was an unimaginable amount of planning and hard work that went into the medical and nursing side of the ICU preparations for COVID-19.

From a physiotherapy perspective, that work involved examining how to identify and train people to work in intensive care.

‘Physios who had previous experience working in the ICU were identified and re-familiarised with the ICU environment,’ Scott says.

‘Staff also spent time identifying physiotherapists who had previously worked in critical care, while not necessarily in the ICU, and rapidly tried to upskill them so that at least they might be able to see less acute intensive care patients, whether they be COVID patients or not, to free up the ICU trained staff to see the more complex patients.

‘So we got to the position that we felt, as a physiotherapy service, that we could probably (comfortably) support about 120 to 150 ICU beds with the staff and training that we had.’

Scott says that, while it likely would have been manageable, ‘there’s no denying that 300 ICU beds would have been a huge stretch, a huge challenge. It would have been a very, very tough ask if we got to that.’

The Alfred Hospital is focused on looking after its workforce, and as a measure of that the hospital had dedicated individuals working to ensure that personal protective equipment (PPE) was being worn correctly. 

Scott says ‘everyone was engaged and empowered with pulling others up on mistakes such as touching your mask or the gown not being worn correctly.’

It was—and is again, due to the resurgence of cases in Victoria at the time of writing—a team effort in ensuring everyone is doing the right thing in regards to wearing and utilising correct PPE.

So far, the system of looking out for each other seems to be working.

‘We are fortunate from both a physiotherapy point of view, and an all-over health point of view, that we didn’t have any patient-to-staff or staff transmission within the intensive care unit setting.’ Scott says.

In order to limit the team’s exposure, Carol Hodgson says that if it wasn’t necessary to enter a COVID-positive patient room, it was avoided.

She says that ‘to reach the point of working out whether or not you needed to go into the room took a lot of time because of all of the necessary PPE.’

Being able to treat COVID-19 patients in the ICU takes more time than treating other patients due to the strict infection-control guidelines in place.

'These are heightened in the ICU due to direct contact with patients with the coronavirus.'

Carol explains how, at the time of interviewing, before the second wave had fully impacted Victorians, when working with COVID-19-positive patients or simply stepping onto the ward, ‘we have to wear our normal outside clothes that we wear from the car to the physiotherapy department.

'Then we have to get changed into our own scrubs to go from the physio department to the ICU. Then, if you’re seeing a COVID-positive or a COVID-suspected patient, you have to get changed into ICU scrubs and leave your [own] scrubs in a locker in ICU … Then you have to don the full PPE to get into the COVID pod, and then you have to prepare even further to get in to see the patient.

‘And all the while the communication between the COVID pod and the COVID patients is really difficult because you can’t open doors, you can’t hand over as you normally would,’ Carol says.

‘Everybody is in N95 masks, and it’s actually very difficult to understand what people are saying. The phone handles have all been taken off, so you have to speaker dial from the open area through to the patient room and have a conversation with the nurse inside the room about whether or not the patient even requires an assessment or treatment from the physio staff.’

Communication on the ward was incredibly challenging and, again, time-consuming.

‘You can’t carry your normal pens and notes, so you have to try and read and remember absolutely everything. Then you go in and you see the patient and you have to try and remember everything there—all the settings on the ventilator, the drug doses, the oxygen doses, your assessment findings and the patient’s response to treatment.

'You leave the patient’s room, come back out and do your notes, thinking “Oh my God, what was it that I was doing for that half hour?” It was very tiring and overwhelming for the first few weeks.’ 

In order to see a patient, the physiotherapy staff ‘really had to justify the benefit of going and seeing a patient.’ Meaning the physiotherapy staff had to converse with the medical staff through many layers of necessary PPE to decide what course of treatment would be best for the patient.

This caused a lot of conversation and critical thinking regarding processes about infection control.

Scott says it was important to limit contact, but also maintain an open line of communication.

This change, he says, ‘was positive because it stopped us just going into auto pilot and it made you liaise with the medical staff, with the nursing staff, and work out what the scheduled need is for that patient for that day.’

At the beginning of the surge in cases in Australia, Scott says there was an increased level of anxiety for everybody but, understandably, the junior staff in particular were in need of support.

‘Scott and I had lots of conversations one-on-one and with our senior team in how we were going to support our team, and it was very much lead by example,’ Carol says.

In order to support the junior staff, one of the senior staff are always on call.

Carol says, ‘we were always going to be available, we were going to be the consultant physio available to any of the junior team to come and speak to us or to run a problem past us, or if we needed to co-treat or if somebody couldn’t cope for that day—either because they were not well, or they didn’t want to or, in case we had the terrible situation where staff were getting sent home because they were potentially COVID positive.’

There continues to be positives learned from the impact of COVID-19.

‘From a leadership point of view it brought everyone together,’ Scott says.

‘As much as we were physically apart, people became much more aware that different people had different things they needed to worry about so we’re not all the same; we had staff who were pregnant, we had people who had some chronic health issues which we weren’t necessarily aware of.’

The necessity to be frank with colleagues and more senior staff may have fostered deeper relationships between those working on the frontline. Scott and Carol both agree that this is something they will definitely try to carry on post-pandemic— along with being more targeted with patient treatments.

 

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