COMMENTARY

COVID-19: ICU Nursing Capacity and Workload 

European Society of Intensive Care Medicine (ESICM)

April 07, 2020

How one UK ICU geared up for COVID-19 as told to a webinar hosted by the European Society of Intensive Care Medicine (ESICM).

Video and presentation notes courtesy of ESICM. Notes have been edited for clarity.

By Carole Boulanger FICM (Faculty of Intensive Care Medicine), consultant nurse/advanced critical care practitioner, Royal Devon & Exeter NHS Foundation Trust.

Even before the COVID-19 pandemic critical care in England had a nursing vacancy approaching 10%. Staff were leaving the workforce due to the ethical climate in the ICU, having to face morally distressing situations related to end of life decision-making, combined with irregular and long shift patterns, low staffing levels, and increased patient ratios. ICU staff, who were already at risk of burnout, are at much greater risk today.

Staff at the bedside are major assets, who need to be cared for as much as the patients themselves.

The information from China, Italy and Spain is vital, as it allows the NHS to prepare, to be proactive, to build resilience in its staff, and to identify issues early. The Italian data show that healthcare practitioners (HPCs) are at risk, with 15% being infected with the virus, 10% of whom are admitted to the ICU.

The risk of infection from patients, necessitating the use of personal protective equipment (PPE), raises anxiety levels for all, is physically demanding, and presents a barrier between the nurse and their patient, and their colleagues.

New teams and new working practices need to be established, setting out a foundation for staff to look after one another and thereby look after patients. It is clear that critical care networks are vital to generate and manage effective pandemic plans, and that extensive and ongoing PPE training is essential.

Nursing Considerations: Existing ICU Staff

Critical care nurses need to prepare for a new way of working: they will become supervisors of care for multiple patients, rather than managing complete episodes of care for the individual patient. They will be supporting and directing the redeployed workforce, providing supervision and expertise in the delivery of critical care. They will be under increased pressure to teach and train redeployed staff in the ‘pre-surge’ period. They need to cease all unnecessary work-related activity, and up- or side-skill to supervise and support others in delivering care.

Whereas the pandemic will increase pressure and introduce challenges to providing safe, effective, quality care to critically ill patients, the primary objective is to act in the best interests of the patient and the public according to professional guidance. Nurses need to be made aware that care may not be perfect in terms of the pre-pandemic ICU, and that this is acceptable.

The relationship between ICU staff and patients has also changed dramatically: patients have become a significant health risk to staff, and maintaining a therapeutic relationship between the nurse, the patient and their families, is challenging.

ICU staff have had to change the way in which they interact with the patient’s relatives and loved ones, communicating by phone/Skype instead of face-to-face. The three-way relationship of nurses supporting the family to support the patient has been lost, and new ways of communicating need to be established.

Expanding the Critical Care Nursing Workforce

Increasing the ICU workforce should be phased, avoiding high numbers of staff in the ICU early on, escalating in line with increasing bed capacity. The workforce can be supplemented by individuals with a range of experience: nurses with recent or previous critical care experience or some transferable skills; registered nurses with no critical care skills (who may prefer task-related activities and clear direction); non-critical care staff in critical care; assistants or helpers; and turning teams, personal care teams, and proning teams.

Non-ICU staff will not have the same skills and cannot be trained to the same level as ICU staff. They are equally valued members of these new teams, and will be trained with the skills essential for their allocated tasks while also keeping patients safe.

Training can involve simulation (turning, positioning patients and orientation to area); video snapshots of key aspects of care and management; and clinical guidelines and educational packages, including flashcards.

New Ways of Working in the ICU

The new ICU teams will comprise members with a wide range of competencies, skills and confidence.

A team culture (‘we’re all in this together’) should be rapidly established. The new teams and members should be easily identifiable. Psychologists recommend establishing a check-in, check-out system. The use of checklists can help standardise daily ‘routine’. Buddy systems are essential (‘clean buddy’, ‘dirty buddy’), as is strict adherence to PPE protocols, including breaks, to prevent pressure sores and exhaustion.

The staff room should be a ‘safe space’, but should be closely monitored. Each designated CCU should provide a designated critical care-trained supernumerary nurse in charge of each shift for supervision, advice, support and coordination including the new or established cohorted critical care areas.

Logistics

The logistics of providing ICU care in a non-ICU environment encompass strict safety checks, standardising equipment, marking floors and sealing doors, and strict entry and exit routes. Processes need to be set up to enable nurses to call for help (eg, walkie-talkies are effective, and mobiles should be avoided), especially those isolated in side-rooms with no eye contact.

Non-CCU nurses may need to work in pairs to provide one another with support and avoid isolation.

Documentation and Charting

Critical care nursing needs to follow key principles, ensuring that anyone can safely take over the patient’s care, without a detailed handover.

Only the key elements of patient care should be documented, in a consistent manner across patients. Decisions must be made on who collects what information and the role of administrative support.

Key concerns and the plan should be immediately evident to all, with clear goals set at ward round and escalation points established (who and how) in advance.

End of Life

Managing end of life will present key challenges in this new world. Often it is the first ‘face-to-face’

contact between ICU staff and families, and PPE is seen as an intrusion. Families may also have to be informed of the death of their loved one by telephone. Health care workers who are less familiar with end of life need to be supported, and the need to debrief must be recognised.

End of life matters should ideally be managed by the most senior ICU nurse available.

Challenges for Staff

Both the staff supervising and those working a shift face significant challenges. These range from managing a roster and team that is likely to change daily, to concerns about accountability in these changing times. Risk can be minimised by setting clear goals and parameters for the day, with pre-established escalation points.

ICUs will face high rates of staff sickness and self-isolation across all staffing levels, and will need to provide support for junior ICU nurses who take on supervisory roles. Staff will experience feelings of guilt about not working. They may also feel anxious about coming to work and infecting their families with a potentially life-threatening disease.

Staff will also be faced with having to deliver care at a level not normally considered acceptable and to cope with high death rates.

Expectations should be managed at the start, explaining that care will be delivered differently to current standards, and that the time each member needs to adjust and become comfortable with their roles and responsibilities will vary. The aim now is to minimise risk (to patients and staff) and complications.

Early provision of psychological support is vital to help nurses cope with the new ways of working and caring for increased volumes of sick patients, many of whom will die. Checking in and checking out of shifts and welfare calls provide a window for checking how staff are coping.

Resilience (‘adapting or bouncing back after being exposed to stressful situations or adversity’) is not innate. Staff should be encouraged to develop personal strategies, such as creating a balance [of eating, exercise, rest and recreation], yoga, mindfulness, social support, reach out, and supportive social media, but avoiding overload. ICU leaders and nursing colleagues also have a role to play in developing resilience in other staff members.

Several ICU-related strategies can help encourage resilience, including communicating with nurses (especially during isolation in side-rooms), managing patient and family distress, monitoring workload, providing telephone support both on and off duty, and effective leadership.

Nursing staff should be allowed to express themselves, whether to vent their frustrations, or through humour. This support will be needed in the short- and the long-term.

Small, achievable things also help build resilience, such as providing food and hydration, hand and face care, and somewhere to shower and change clothes before going home. Telephone calls to check in when staff are off sick, as well as insisting that staff take days off are important.

Acknowledging that it’s tough, and will continue to be so, for a protracted period, and saying thank you are also valuable.

The Future

The current focus is on the pandemic, but preparations must be made for the future. The new and more diverse team of nurses will require immediate and ongoing psychological support to deal with the long-term consequences. We can and should focus on the successes, but also allow time to reflect and grieve. Nurses may also need to accept a ‘new normal’ in ICU care.

For now, prepare, prepare, prepare, but be flexible and expect frequent changes to plans. Ultimately, caring for the staff will translate into caring for the patients.

Do not underestimate the physical, psychological and emotional effects of the pandemic on the team, which are likely to be long lasting.

This is a marathon, not a sprint.

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