Trusts are developing innovative ways of supporting staff, patients and service users, and managing the risks posed by COVID-19. Clinical teams across trusts are making a series of changes to manage the increase in the number of COVID-19 patients, and to reconfigure existing practices and equipment. Trusts are also making changes at pace to the way their workforce operates.
Great Western Hospitals NHS Foundation Trust worked with local partners, including social care and charities, to bolster care in the community during their COVID-19 response. They created a robust seven day, 8am-8pm service to support patients affected by COVID-19 directly or indirectly. This service reduced acute bed occupancy to 50% at the height of the pandemic’s first peak, as well as a sustained reduction in the number of medically fit patients waiting for discharge and over 21-day stranded patients.
Most patients have gone home with wraparound support. This was possible as staff and volunteers took on duties beyond their normal scope. For example, podiatrists supporting tissue viability nursing services and therapists undertaking care visits.
Central and North West London NHS Foundation Trust (CNWL) set up a COVID-19 first responder programme. This scheme enables staff to volunteer to join the response to any future spikes in COVID-19 demand. During the first peak of COVID-19, staff were redeployed into key services responding directly to the outbreak including rapid response, palliative care and district nursing.
The feedback CNWL received from redeployed staff was positive - they learned new skills and knowledge quickly, as their COVID-19 roles provided opportunities for professional development. This led CNWL to establish a team of staff who, if there was a second wave, are prepared to be redeployed at short notice. This provides a chance for the trust to have more time to reform its other services and then deploy additional staff. Applicants can express a preference for a service where they might be redeployed at short notice if there was a second spike. They are trained and upskilled, with regular ‘touch-base’ days to maintain their skillset and familiarity with the team. The scheme has already identified 140 people to support those critical COVID-19 teams.
The vision for first responders is to become a community of colleagues who can share best practice and latest research and developments of managing people with COVID-19.
Northern Lincolnshire and Goole NHS Foundation Trust led a team of nurses offering and delivering widespread virtual training to all carers in care homes within North Lincolnshire.
When the COVID-19 pandemic was escalating, the majority of care homes significantly reduced health professionals' access to protect their residents. This led to the trust needing to find additional ways to support the carers to effectively identify, review, and refer poorly residents via SPA, with as much clinical information as possible. They worked as a team, with the full support of Project ECHO (launched in 2003, now operating in 39 countries). The ECHO model is focused on creating a community of practice where ‘all teach, all learn’. Being mindful of precious carer time and to encourage attendance, the trust produced a short one-hour basic observations and SPA escalation training session, which included an interactive presentation, video, practice time for carers, and a question and answer session. These sessions were all delivered via Zoom. To date, they have delivered 18 one-hour sessions and trained 310 carers in 47 different residential care homes all over North Lincolnshire. To ensure the carers could use these new found skills, the trust have supplied 14 homes with tympanic thermometers, procured (on behalf of the CCG) 32 electronic BP machines and 39 pulse oximeters for care homes without equipment and distributed 61 tablet devices (supplied by the CCG) so care homes could participate in training and support virtual consultations. SPA have seen a marked improvement in the confidence of carers and standard of referrals making triage more effective, and hopefully in the longer term the team should see reductions in unnecessary admissions to hospital so residents can be treated within their home environment.
Care home managers are reporting carers feel more valued and have really embraced this personal development opportunity, which has been evidenced by multiple attendance from the same care homes or sister homes.
It was recognised that carers would need more support to care for dying residents during the COVID-19 pandemic, therefore Northern Lincolnshire and Goole NHS Foundation Trust initiated the delivery of a virtual training package was initiated.
Three sessions have been delivered via Zoom with 84 staff from 18 providers attending. All attendees were grateful to have received some education and to meet with the end of life community lead who is happy to support home carers and care homes with any end-of-life issues. The project is still in its infancy so there is no hard evidence or data as yet, but the sessions have been well received and with good feedback and the trust feel this is something they will support for some time to come.
A GP role has been created to provide clinical decision making capacity to support community teams that are working to manage patients’ urgent care at home. The role is being evaluated for its benefits for patient care and more efficient working of the local care system. Community practitioners often need clinical advice to be confident that managing a patient at home is a safe and appropriate option. Seeking GP advice (especially out of hours) can be time consuming, therefore, having a GP available is helping to manage patient care in a different way, for example, avoiding hospital admission. The community response team (CRT) GP (provided from 8am to 8pm, seven days per week) is based in the same place as the teams that make up the CRT. The service commenced on 25 April 2020. SafeCare, a federation of local GPs, is responsible for providing GPs to cover the rota.
The COVID-19 hospital discharge service requirements document was released in response to a prediction that acute providers would not have sufficient capacity. The key challenges this document posed were that there were to be no medically optimised patients on the acute site. Therapy assessments would happen in the home, and the NHS will fully fund any new or extended out of hospital health and social care packages.
Patients at the acute site were to move to a discharge lounge once they were medically optimised within one-hour, and discharged from the organisation within two hours. To achieve this, significant changes to system working were required. The decision was taken to re-locate and expand the discharge lounge offer at Royal Derby Hospital, to one that allowed patients to be transferred from the base ward who had incomplete assessments, which were then to be completed in the lounge. This involved redeployment of a wide multi-disciplinary team to deliver this offer.
The discharge assessment unit has supported flow across the acute hospital as is evidenced by the sustained reduction in length of stay for patients across the organisation.
The landscape was ever-changing, with continual changes to modelling predictions. There were daily operational calls with system partners to discuss and problem solve at a patient level but also at a strategic level to enable continuous improvement to make the system work better for those patients whom we serve. The main aim was to eliminate delays, create acute capacity and save lives. Having a shared goal minimised the challenges faced within the system partnerships.
The basis of Chesterfield Royal Hospital NHS Foundation Trust’s existing health and wellbeing model enabled us to enhance and rapidly scale up services already in place, while building in additional resources across the system with our partners in Joined Up Care Derbyshire (JUCD).
Their collaboration across the system allowed for a co-produced support pyramid to be mobilised quickly across JUCD with a focus on mental health and wellbeing. This was implemented before the national offer - utilising existing services, scaling up a pandemic response plan, new psychological support via RESOLVE and introducing the smart app Thrive for all staff.
They also collaborated with our health and wellbeing network and spoke to subject matter experts in areas such as MSK, and a physiotherapist from Rotherham Hospital, to discuss implications when working from home.
Ashgate Hospice and staff 1-2-1 support sessions (legacy project) were implemented quickly. Following feedback on their positive impact, more sessions are now funded for a further year to offer ongoing staff mental wellbeing support.
Surrey and Sussex Healthcare NHS Trust found an innovative solution to meeting the challenge created by the sudden increase in demand for intravenous antibiotics needed for COVID-19 patients.
With depleting numbers of frontline nursing staff due to shielding and self-isolation, along with nurses being deployed to unfamiliar clinical environments and encumbered by PPE, the challenge centred around a growing mismatch between demand for IV antibiotics and ability to supply them. There was concern that failure to address this mismatch could result in reconstitution errors and significant variation in dosing intervals which could have tangible impacts on treatment efficacy and/or patient safety.
The trust wondered - could nurses unable to work on the frontline but familiar with the process of preparing IV medicines form an IV antibiotic reconstitution team, working away from the ward area, releasing the nurses on the wards for other tasks and mitigating the risks that we had identified?
The trust has no aseptic dispensing facilities, but having temporarily halted elective surgery, the possibility of using an empty laminar flow operating theatre as a “clean” area in which to prepare IV antibiotics was proposed. After careful review of the Medicines Act and Human Medicines Regulations 2012, (approval by the trust board) the pharmacy team drew up careful and thorough plans so that a nurse-led pharmacy supervised emergency reconstitution service could be provided.
Over a period of four weeks – at the peak of the pandemic – 1000 doses of IV antibiotics were prepared and supplied to clinical areas, enabling ward-based nurses to focus on caring for their patients. Work is underway to determine if there would be value in the team preparing a wider range of products, particularly those which may be of particular use in critical care areas.
Three days before the country was put into COVID-19 lockdown, West London NHS Trust opened an acute mental health ward, reconfigured to care for patients with mental illness requiring urgent treatment in hospital who test positive for COVID-19.
Avonmore Ward in Hammersmith and Fulham was the first of its kind in the country.
Over a couple of weeks in March, the team came together from across the trust – most of whom didn’t know each other and hadn’t previously worked together – to care for patients’ mental and physical needs at a time when they were likely to be at their most vulnerable.
Alliance provides short-term interventions to young people and their families in crisis, with the aim of preventing hospital admission. During the initial phase of the COVID pandemic, the team saw that the burden of care was falling disproportionally on parents without the usual professional and personal support structures in place. Concluding that a virtual forum could help, an online parent support group was co-produced. The group is facilitated by two clinicians and attended by five to seven parents for an hour via Zoom. This initially began with general discussion followed by a presentation on an agreed topic. After a review, this moved to a full hour of general discussion. Facilitators have supervision from a family therapist.
Ground-breaking research, funded by Diabetes UK, found a supported, low-energy diet can help people with type 2 diabetes achieve remission (i.e. normal blood glucose levels without the need for diabetes medication). A low energy diet programme consists of three stages and takes one year to complete.
In March 2019, the Hackney Diabetes Centre (HDC), became one of the first NHS services to offer a low energy diet programme targeting T2DM remission. Since then, three groups have completed the programme (19 participants) with a fourth (11 participants) currently in the middle of the weight maintenance phase. The programme is led by diabetes specialist dietitians with the support of diabetes specialist nurses and a psychologist with the team providing a total of 20 group sessions in the year. To date the programme has seen a great deal of success for those participating with an average weight loss in 12 months of two stone.
In early 2020, Homerton University NHS Foundation Trust were approached by Pocket Medic, a digital platform that allows clinicians in primary, secondary or community care, to send film-based prescriptions to patients to help manage their chronic disease. Pocket Medic had been commissioned by the NHS to film patients going through a low energy diet programme to help raise awareness among clinicians and public. Many of our patients were keen to share their journey and as a result, helped create a number of videos showing their progress. The trust are very proud of our service and the participants who have given so much to improving their health, we hope these videos help others achieve similar results.
During COVID-19, the referral hub’s services were boosted, following the newly-introduced prevention of admission (PoA) enhanced pathway. The trust's integrated care teams provide the PoA, with responsive and urgent care for people in their own homes, reducing the need for acute hospital care. New pathways for intravenous antibiotics, intravenous diuretics and deep vein thrombosis were developed and implemented, including use of point-of-care testing equipment and an electronic prescribing service. The team includes nurses, therapists and pharmacists, supported by GPs, using virtual consultations. This multi-disciplinary team is available seven days a week, 8am to 8pm, with urgent nursing service covering nights, 8pm to 8am.
At the start of their COVID planning, alongside colleagues from Tees Valley Clinical Commissioning Group, Tees, Esk and Wear Valleys NHS Foundation Trust brought partner organisations together to coordinate a needs-led approach that would support the mental health and well-being of children and young people during the pandemic.
Initial conversations were about how voluntary sector partners could support with delivering services to people with mild to moderate needs on our current caseload and new referrals. A network of providers was established, and a weekly meeting set up to plan a whole system approach.
A new ambulance streaming pod at London North West University Healthcare NHS Trust helped to improve the emergency care of patients arriving by ambulance. The pod, which opened on 14 April, enabled clinical staff to direct patients to the appropriate assessment area rather than going through the emergency department.
Crucially, during the COVID- 19 outbreak the pod ensured that emergency patients with respiratory conditions were kept apart from those with non-respiratory conditions.
During the pandemic, approximately one third of COVID patients admitted to intensive care units (ICUs) developed kidney failure requiring dialysis.
Northwick Park Hospital (NPH) was one of the first, and hardest hit, needing to more than triple its ICU capacity with many patients requiring dialysis. The challenging situation led to staff conceiving a novel approach to provide haemodialysis within the ICU, ensuring continuity of this life-saving therapy to critically-ill patients. NPH became the first ICU in the world to use an innovative method of dialysis embracing and utilising mobile home dialysis machines. A partnership between the trust and Imperial College Healthcare saw the deployment of NX Stage dialysis machines. The machines do not require replacement pipes or special fluid and operate more quickly than hospital machines, meaning they can be used on several patients a day.
The machines are usually used by patients who have permanent kidney failure, to dialyse at home. The trust used the machines, to provide an alternative and reliable method of dialysis in the ICU. The innovation ensured patient safety and relieved pressure on the overwhelming demand for the standard dialysis technique.
The challenge presented by COVID to the pharmacy team at Northwick Park Hospital was twofold. Firstly, they needed to find a safe way for patients to collect their prescriptions from the hospital pharmacy. Secondly, they had to offer a pharmacy service to those hospital outpatient clinics that had switched to running virtual appointments.
A drive-through pharmacy, introduced at Northwick Park Hospital, enabled patients to collect their ‘hospital only’ prescriptions quickly and safely without the need to go into hospital The pharmacy team started planning the drive-through service on 20 March and it was up and running just seven days later, on 27 March.
Patients received a text or phone call advising that their prescription was ready for collection. The drive-through design meant that patients did not need to find a hospital parking space or even get out of the car. The service was staffed by the pharmacy team and included a pharmacist, able to discuss the medication with the patient and answer and questions. The drive-through service could also be used safely by those patients coming to hospital on foot.
Coronavirus forced the shutdown of major surgery across the UK. Royal Surrey NHS Foundation Trust had an ambition to maintain cancer surgery and continue to provide high quality surgery across our cancer alliance in a safe environment. At the trust they continued to run cancer diagnostics, endoscopy and surgical services throughout the pandemic.
To do this, they created a COVID-free zone in partnership with NHS and private provider, and cancer hub. Moving their robots to the day surgery unit allowed our surgery teams to continue to operate on gynaecological and urological cancers, with approximately 160 robotic procedures carried out during this period and no current backlog.
The team efficiently and effectively set up five-day week, two-theatre robotics service at a time of great uncertainty.
Professionals from across the Cornish health system mobilised to quickly establish three CATUs in April 2020. The aim was to prevent the admission of frail elderly patients into the main acute hospital, which it was anticipated would lead the county’s response to COVID-19. A GP and nurse-led model with named consultant support; the CATUs are located in Bodmin, Camborne and Penzance.
The CATUs support older people with frailty syndrome or those who have fallen, have poor mobility, dementia, delirium, Parkinson’s disease or who are care home residents. Patients with lower frailty scores are also admitted if it’s considered their condition will worsen or whose end of life care cannot be managed at home. This has enabled people’s end of life wishes to be made possible.
The aim was to reduce the number of frail elderly attending the emergency department, by upskilling staff and enabling primary care networks to care for more people, closer to home. The short length of stay is designed to help keep people safe and minimise the debilitating impact of long hospital stays.
