The Early Supported Discharge (ESD) team in Cork provides specialised domiciliary stroke rehabilitation.
As an integrated stroke service, ESD constitutes a vital rehabilitation pathway for stroke survivors facilitating patient flow through acute stroke units in Cork University Hospital, the Mercy University Hospital and St Finbarr’s Stroke rehabilitation unit since starting in 2018.
Prehabilitation is the concept of increasing an individual’s exercise capacity to physically prepare them for their upcoming surgery. The OpFit prehabilitation programme is a pre-operative exercise programme for patients who are scheduled for cancer surgery in St. James’ Hospital. We have based our programme on the current research on pre-operative rehabilitation, and also the Macmillan “Principles and Guidance for Prehabilitation within the Management and Support of People with Cancer” (2019).
Medical scientists are unique healthcare professionals. We play a pivotal role in the diagnosis of disease and treatment of patients. Yet, we never meet them, in fact, most don’t even know we exist.
Although we don’t see the faces behind the samples, the patients are in the forefront of our minds in every step of our testing procedure. This remains the case during this pandemic where we must ensure we can stand over and trace every aspect of the process, from sample collection through analysis and results.
Starting from Scratch
When we made the decision to introduce in-house testing for SARS-CoV-2, we didn’t have the existing equipment required or enough staff to maintain the service. Thankfully, close links to UCD provided us with both equipment and scientists to help get us off the ground. Our medical scientists welcomed that assistance and worked round-the-clock to validate all the necessary components.
The procedure for SARS-CoV-2 involves a number of different steps. When samples are received, as with all samples, they are checked to ensure identifiers on swab and form match. A lysis step is next, where buffer is added to some of the liquid media from the patient’s swab. This lyses cells and inactivates the virus making the sample safe for further processing.
An extraction procedure follows, to isolate and purify the viral RNA (genetic material), if present, from the patient sample/lysis buffer mix. The final step in the pathway is RT-PCR. Viral RNA, is converted to DNA and this DNA is amplified and measured by the PCR instrument.
All procedures along the way need to be validated and internal controls are included in every step, in every run. Despite the enormity of the task, less than a week after the decision to start testing, we reported our first results.
Dealing with Rapid Change
The first few weeks went by in a blur. Everyday brought new challenges and as soon as one issue was resolved, another arose; reagent shortages, consumable shortages, equipment issues.
Throughout this eight-week period we have used four different lysis buffers, four different extraction methods and four different Real-time PCR methods, each needing validation before tests results can be released. Results were sometimes delayed as we battled uncooperative equipment or technical issues. I stumbled out of work in tears after some very late nights.
Challenges during Challenging Times
I expected the validation of a brand new test to be challenging. A challenge that I hadn’t anticipated was the public perception of medical scientists. From being a largely unknown profession outside of hospitals, suddenly we were in the spotlight. Sampling and testing were commonly confused.
Everyone was demanding to know what was taking us so long. Why couldn’t we just make reagents/get analysers/test faster? After working countless hours to validate new systems to ensure quality of results, it sometimes felt like a personal attack, even though the situation was out of our control.
Currently our supply chains seem robust and our orders are maintained through a centralised HSE network where reagents/consumables are allocated depending on test capacity.
Teamwork in a time of crisis
A whole new section in our department was created in a week, and we still had to process all our normal microbiology specimens. We had to divide staff into teams to allow social distancing and limit contacts.
Staff also had to contend with the same issues that face front-line workers throughout the country including childcare and worry of possibly infecting family members at home. Despite these difficulties, the laboratory staff came together to make it work.
As a team, both in St. Vincent’s University hospital and in the Medical Scientist community as a whole, we have grown closer and stronger. A network, between hospitals and departments, which luckily always existed, was now called upon more than ever to share experience and loan/swap reagents.
Staff members have driven reagents to different hospitals and another hospital allowed us to use their equipment when one of ours broke down. Staff at the National Virus Reference Lab (NVRL) have helped provide materials to use for validation and have shared validation procedures, despite being incredibly busy.
Less than two months after that first test, we have now tested over 6,000 samples. We have the capacity to test 200 samples/day seven days a week and our turnaround time for results after receipt of samples into the laboratory is between 8 and 30 hours.
We also have a one-hour RT-PCR assay for urgent samples. We have come a long way in eight weeks and we are aware that there is a long way to go but we will continue to test, test, test; always remembering that behind every sample is a patient.
This Blog was written by Deirdre Keating (firstname.lastname@example.org), Specialist Medical Scientist, St. Vincent’s University Hospital.
Over the weekend, I reflected on the effect, dynamics and response of our team of 16 Cardiac Physiologists to these unprecedented COVID weeks.
Anxiety, Communication and Self-care
Given we perform and report cardiac tests on patients, there has been anxiety of contracting or passing COVID to patients, particularly during cardiac ultrasound, a close contact procedure.
There was the uncertainty of the situation, possible redeployment and how the health service would cope. There were also individual concerns regarding family, particularly older relatives.
We had an initial meeting where all concerns and thoughts were raised in an open way. Questions were answered honestly, where information was available, but there were also a number of “I don’t knows”.
We hold daily huddles, to update on rapidly changing work practices and set-up a COVID Info group in addition to our longstanding work WhatsApp group, so everyone had relevant information on their device. Our team was directed to information sources, such as the WHO and HSE. As a team, we feel these daily huddles reduced anxiety and improved communication.
Our mantra is to “get through this with our health and relationships intact”. To aid this, infographics about stress management and self care from @whw_HR have been shared. This weekend, I shared “Hold onto your red thread” an article from the BMJ – mine are cycling, home life and minding our team.
30% of COVID patients develop cardiac issues, with a number requiring cardiac ultrasounds. Protocols reflecting international guidance were rapidly adopted. Twitter has been great at keeping us updated on guidance and also showing how other centres and leaders in the field have been dealing with this.
Within one week, we developed processes for safely treating patients with COVID, who were also suffering from heart attacks. This involved the 24/7/365 Heart Attack (CODESTEMI) team, nurses, doctors, radiographers and ourselves.
Although non-time critical diagnostics were cancelled, our long-standing use of remote monitoring technology, where implanted devices can be checked from patients’ homes, has allowed us to continue to provide follow-up for these patients.
We have noticed over the last number of weeks, after cocooning was instituted, that phone calls with these patients takes longer as they seem to enjoy the chat. We also observed that chatting with inpatients who require tests was even more important than usual. They are missing their visitors – the suggestion is to ask at least one non-clinical question.
We also rapidly, with support of IT, integrated reports from all of our testing equipment onto the hospitals Electronic Health Record.
Split teams – challenges and benefits
Cardiology split into two teams, working different shifts on alternate weeks. This was designed to protect the service from being wiped out by infection. Within three days, through open discussion, we had managed to work out shifts which aligned to medical and nursing colleagues and provided extended hours diagnostics, six days a week, to support a non-COVID Emergency Department in the Acute Medicine Unit.
New extended hours are quite tiring for staff and people are missing colleagues who are not on their team. However, there have been a number of benefits; the smaller teams provide opportunity for staff to take on more responsibility and colleagues have got to know each other better. Both teams have tried to keep spirits up, lots of baking, some laughs, minding each other, and goodies being left for the team taking over.
I was concerned about not meeting the other team but am having a number of WhatsApp video calls to keep in touch, although I might benefit from them most.
There is a huge sense of pride in our own team, how they have adapted, grown, got stronger and minded each other. Pride in our HSCP colleagues, Radiographers – performing tests on COVID patients, Med Lab Scientists – responding amazingly to ramp up testing in difficult global conditions, Medical Physics staff – procuring, commissioning and checking huge amounts of equipment to get us ready, Physiotherapists, Dieticians, Speech and Language Therapists, to mention a few – working in critical care areas and COVID wards.
There is also pride in our leadership at national level; Simon Harris, Dr. Tony Holohan and his team and the Irish people whose adherence to restrictions has helped prevent the surge.
This Blog was written by Paul Nolan, Chief Cardiac Physiologist, University Hospital Galway. @pnolan99. email@example.com
I can distinctly recall the date of the first Covid-19 patient that was admitted to St. Luke’s Hospital in Kilkenny. Ironically, it was on Friday, the 13th March, 2020.
It was so rehearsed, systematic, an ideal scenario in fact – the patient was calmly examined in a dedicated isolation room. ‘Recent travel from China’ read the clinical indications on the X-ray order.
We have come a long way since then. Now we are led by daily algorithms and HPSC updates have dictated new work-flow operational practices for Primary Care centres, ED staff and in turn, radiographers.
Referral criteria for chest X-rays and CT scans have been modified in line with best international practise. Operational workflow arrangements to deal with both COVID and non-COVID work streams have been organised so that the care streams never meet, in order to minimise infection crossover risk.
Digital mobile radiography is the new standard to reduce the transfer of infection. Strict infection control measures are adhered to – “donning and doffing” are the new buzz words for radiographers. We have also introduced a Buddy system to minimise cross infection whilst X-raying COVID patients.
Many patients, either intubated or on admission to the Medical Assessment Unit, appear agitated as the infection takes hold. This makes the whole event of performing a mobile X-ray tense as conversation with the patient is limited. These conditions make it difficult to empathise with the patient.
I am a well-seasoned radiographer and I have found it heart-breaking to work in these circumstances, only to find that, in some cases, the patient has unfortunately passed some days later.
I’m now an expert in PPE. I can discern the quality of good PPE from a mile off. I spend much of my day in a whole white body suit that was not so long ago commonplace on media images we saw from Italy and Spain. Where initially there was one patient, now there are often four to five portables to be performed in a COVID ward.
The suits are hot and difficult to move in but a necessary evil. I keep telling myself that I will never take another free dessert from the canteen again, but my willpower is shocking.
It has been six life-changing weeks since the crisis took hold and there is no sign of it abating any time soon. My physical and mental well-being is tested on every shift. Equally though, valuable lessons have been learned and strong work friendships formed in the face of hourly adversity and crisis.
There have been many days and nights since this crisis started that I have questioned why I ever become a Radiographer. I lost a good friend just last week and discovered this awful news by casually looking up RIP.ie whilst I was on call.
I was not able to attend her funeral or pass my condolences to her family. There is no longer a vent to express the normal phases of grief. I have lost work colleagues and the realisation that I too may succumb to COVID 19 is never far from my mind.
I am not a great cook or champion organiser but since the crisis has begun, Nigella, Kevin Dundun and Nevin Maguire are strewn across the kitchen table. Blobs of flour and egg shells mark my attempts at becoming the next Nigella.
My teenage children can sleep for Ireland but they have, on a couple of occasions, acknowledged what I do for them on the frontline … and that has brought a tear to my eye. I realise I am a radiographer because I worked hard to be one and that example is what I want to impart onto them.
The weeks do pass and I have a diary noting the dates that Occupational Health have phoned to say I was either a close or casual contact. Little else goes into it. My social diary is clear. However, the weather outside is getting better and with that brings hope …
This blog was written by Kate Murphy, Radiation Protection Officer, St. Luke’s Hospital, Kilkenny with support from all the Radiography team in St. Luke’s Hospital.
This has been the most challenging 4 weeks in my 20 years of practice for many reasons.
Looking for certainty at a time of complete and utter uncertainty has led us to reach out and make meaningful connections locally, nationally and internationally which has been a double edged sword. It has brought a lot of meaningful discussion but has also given us a thirst for knowledge and evidence that is emerging but may take months to be conclusive.
In the meantime, we question ourselves relentlessly; trying to reduce our clinical worth to what is deemed essential and non-essential has been exhausting and, at times, a little degrading.
The endless debate on PPE has allowed us to fear our patients. We fear the risk we pose to them. We fear the risk they pose to us. We have also been asked to question our worth to the patient’s care. Do you really need to do your job?
The reality is that rates of under-referring to the HSCP group was prevalent pre-COVID-19. This is not a time to exacerbate this situation. This is a time to come together to prove the integral role we all play in a comprehensive holistic pathway of care.
For the first patient I went to see 4 weeks ago, I was so dysfluent in the process of donning and doffing the PPE, I arrived a little distracted. The discussions on how far to stand away from the patient made it harder to do what has always been a fundamental part of my assessment. To look someone in the eye and apologise that they are in Hospital, but reassure them that they are in the right place.
The second time I went in, it got easier. It has also become easier to offer constructive help to my colleagues; can I schedule my assessment at the same time as they need to be turned? I can help. When do they need oral hygiene done again? I can do this. Are they taking meds? I can assess whether they can manage these orally.
There is a debate raging that oral hygiene may no longer be part of our essential role. I cannot agree with this. Not when I have assessed and treated multiple patients in the last few weeks; some extubated after prolonged ventilation, some on NIV hoods, some on airvo, some self ventilating.
COVID-19 requires a very different approach to normal respiratory conditions. Humidification is not necessarily part of the treatment. Dehydration is common and sometimes life threatening. Oral xerostomia and risk of candida are common.
An essential part of my role has been to ensure that all patients are entitled to oral hygiene via suction toothbrush. It is more common practice to administer oral hygiene via small pink sponge swabs. I’m not sure how this ever became normal. An ex-patient likened it to Christ on the Cross and the sponges of vinegar!
It is undoubtedly more comfortable for a patient to have their mouth cleaned with a toothbrush, and when they are unable to manage their own saliva, the risk that this oral care poses to the lungs is significant and life threatening.
It is essential to raise insight into this and help people understand that the suction toothbrush not only saves the patient from aspiration but also protects the person completing the oral hygiene as it is a closed suction system. Being able to support the Nursing Team so that it can be provided every 2 or 3 hours prevents the build-up of candida on the tongue. This is vital to prevent another source of aspiration and pneumonia.
I have now completed an episode of care with a person who was admitted, although within the younger age category, with multiple comorbidities. He was intubated for 10 days, experienced seizures and delirium as a result of severe dehydration and had not been able to see or speak to his family for 35 days.
What did a week in that pathway of care look like?
Working with my Nursing colleagues to provide oral care, to commence cautiously on oral intake and to determine how to enable the person to communicate basic needs
Working with my Medical colleagues in Infectious Disease, Renal Medicine and Neurology to define delirium versus neuropathy, confusion versus cognitive change and to determine capacity to meaningfully participate in decisions on delivery of care. All of whom are interpreting the diagnostic results analysed and reported from my HSCP colleagues in Medical Science and Radiography.
Working with my Physiotherapy colleagues to minimise risk of aspiration from oral secretions and oral intake, and to enable the best expiratory flow for voice, cough and swallow.
Working with my colleagues in Clinical Nutrition and Dietetics to enable the best regime for nutrition and hydration in the context of a severe oro-phayrngeal Dysphagia.
Working with my colleagues in Pharmacy to ensure the right consistency of oral medication.
Working with my colleagues in Occupational Therapy to enable positioning for therapy and self-feeding.
Finally, the icing on the cake at the end of an intense week, was enabling my patient to have a cup of hot (modified) tea, while we whatsapp video-called his family as I interpreted, so they could understand his dysarthric speech. The joy in the reunion, after 23 days of not seeing each other, was immense.
All in all, not a bad week in the office.
This Blog was written by Aideen O’Riordan, Deputy Speech and Language Therapy Manager, Cork University Hospital
Recent weeks have seen massive disruption to healthcare services as we grapple to meet service need in the context of the COVID-19 pandemic.
Over the past six weeks, the SCOPe Directorate* in St. James’s Hospital has pivoted from primarily in person assessment and review to a teleHealth model. This Blog will set out the key enablers that made it possible to achieve this change at pace.
* The SCOPe Directorate is the HSCP clinical structure in St James’s Hospital consisting of the five departments of Medical Social Work, Speech & Language Therapy, Dietetics, Occupational Therapy and Physiotherapy.
Our SCOPe team is no stranger to digital developments having led the digital transition from paper to electronic patient records (EPR) with all documentation transitioned by end of 2016. This improvement project was highly structured and a SCOPe EPR QI team managed implementation and governance.
The vision has always been to progress patient engagement, teleHealth solutions, shared records, patient portal etc. in structured phases.
Looking back, our experience and vision laid the foundation for digital readiness in the HSCP workforce, giving us a big head start when news of COVID-19 emerged.
Our Journey to a teleHealth Model
In early March, the SCOPe eHealth QI team had a brainstorming session to explore the potential of teleHealth to support patient care as the situation evolved.
Services identified as potentially suitable for transition varied as HSCP staff work across all episodes of care including ED, in-patients and outpatient clinics.
Over the course of the following week, the SCOPe directorate moved to provide urgent assessment and review to all OPD services using a generic teleHealth platform.
Electronic appointments and an EPR are already in situ in St. James’s Hospital so the immediate need was to provide a safe, secure substitute for the face-to-face component of the therapy assessment.
Colleagues in the IMS department provided invaluable support including:
organising app demonstration
enabling of infrastructure
provision of licences for staff
Concurrently, the SCOPe team worked to develop:
flow around implementing the teleHealth application
mechanisms for measuring activity while supporting staff in the introduction of the teleHealth app
Our Learnings So Far …
Feedback has been positive as the teleHealth model allows ongoing contact with patients who require HSCP input.
There is an acknowledgement that it is not ideal for all patients. However, staff report that they are getting better at identifying those patients for whom a virtual teleHealth clinic will work best and at adjusting their communication style to aid rapport development.
In some cases, the teleHealth clinic exists alongside a telephone clinic depending on the patient’s technological abilities.
There have been teething problems with Wifi /4G availability on the patient side and clear instructions are required on how patients can best manage their device for camera visibility.
This use of digital solutions to facilitate ongoing patient management is happening in parallel to the use of virtual tools to facilitate department communication and training.
Where social distancing cannot be observed, significant value is added by the inclusion of virtual video conferencing for education sessions on clinical preparations for the COVID-19 emergency, in-services, journal clubs and meetings.
There is a learning curve with using this technology … a need for collective understanding that technology may fail, cameras may freeze and small visitors may make an appearance in the feed of those working from home!
While it is not always as successful as a group face-to-face meeting, it is a very acceptable alternative when staff can’t all be present in the same room, at this time.
As well as this, a campus-wide staff communication tool has been implemented in the last two weeks. This has also proven very beneficial for urgent communication from the hospital leadership team and this secure confidential messaging service can also be used to support communication in relation to clinical information.
Most of all, it is clear that the well-plotted transition to EPR created the conditions for readiness amongst the HSCP workforce in the following crucial areas:
While teleHealth developments in St. James’s Hospital were already under development, COVID-19 greatly accelerated implementation! By far the greatest asset has been the staff who were required to be ‘early adopters’ of change, learning as part of the doing rather than ahead of implementation.
It has been a huge undertaking and SCOPe HSCP have adapted admirably, motivated by the fact that these changes would lead to effective alternatives to direct patient care for service users.
This Blog was written by Joanne Dowds on behalf of the eHealth HSCP Advisory Group. Joanne is a clinical specialist physiotherapist working in the ICU of St James’s Hospital.
Over the last few weeks, I have seen first-hand the vital role HSCP are playing in response to the COVID-19 pandemic.
HSCP are carrying out diagnostics and disease monitoring
HSCP are delivering specialist treatment and rehabilitation
HSCP are providing psychosocial and practical supports to patients and their families
HSCP services are needed at each stage throughout the patient journey and as such, it is incumbent on us to ensure we have the necessary information and resources to undertake our roles.
In my last Blog (on April 5th), I focused on general resources available to HSCP in the context of the COVID-19 pandemic. Today, I am sharing more resources, relevant to specific professions* within the HSCP group.
Unfortunately, it is not possible to represent all 26 HSCP disciplines in one blog post. Therefore, I have included a sample of professions from the therapy, diagnostics and social care domains of the HSCP group. If your profession isn’t included and you would like to share resources, please do so in the comment box below. We would be delighted to hear from you.
INDI has provided learning resources on COVID-19 to assist dietitians being redeployed to hospital wards and ICU clinical roles. These resources are accessible to members and non-members of INDI (via the guest login). The INDI website also has a range of resources on healthy eating for all ages, from older adults cocooning at home to young children and families. These are for the public, carers and health professionals.
Abbott Nutrition has shared a webinar, recorded in 2018 with Irish ICU dietitians entitled ICU Nutrition Made Simple. A range of pertinent questions are addressed including: the nutritional requirements through the different phases of critical illness, the requirements of the obese critically ill, refeeding syndrome in ICU, indications for parenteral versus enteral nutrition and how best to monitor to monitor patients with complex needs.
Clinical Dietetics online provides a course on Mastering the Nutrition Care Process which can be accessed via the free 1-month trial (membership is $5.99 per month thereafter). Registration with this site also includes updates, blogs and discussion fora, accessible via the dedicated app.
The ACSLM provides links to information and guidelines for their members as well as highlighting relevant podcasts and other resources. See https://acslm.ie/?p=3756 for details.
The newly released Oncall Buddy app, developed by Consultant Respiratory Physiotherapist Stephanie Marshall and Physiotherapist Iain Loughran is another great free resource for those working in respiratory.
Finally, Physiopedia offer a free Coronavirus Disease Programme on their trial account. However, caution must be exercised due to variances in terminology and policies between the UK, US and Ireland.
The American College of Radiology has published guidance for radiology departments to support adaption of work flow practices, particularly in relation to infection control.
Other educational opportunities are available on Radiopeadia and on MRI Online, the latter providing a free course on COVID-19. This course demonstrates the typical CT scan findings of COVID-19 pneumonia and how the findings progress over the course of the disease.
The IASW has developed a COVID-19 Resources section on https://iasw.ie/covid-19 which is regularly updated with new and emerging information and supports for social workers. A guidance document for the medical social work profession response to COVID-19 has also been developed to support social work which plays a pivotal role in bereavement work with patient, family and staff support.
* Please be aware that information and guidelines in this area are changing rapidly. Although these resources are up to date at the time of writing this blog, they may be superseded by new guidance in the coming days and weeks.
This Blog was written by Éadaoin O’Hanlon on behalf of the eHealth HSCP Advisory Group.
“The best part of learning is sharing what you know”
Vaughn K. Lauer, Author
What does COVID-19 mean for me?
How will COVID-19 affect my clinical practice?
How can I best support my patients?
And protect my own health?
Since the outbreak of COVID-19, my head has been filled with many questions. As a physiotherapist working in an acute hospital, I am used to caring for patients with respiratory conditions and am accustomed to working in a critical care setting.
However, that does not mean that I am any less daunted by this novel disease. From speaking to HSCP working in other settings across Ireland, I know I am not alone. The outbreak of COVID-19 is without a doubt a massive challenge for all HSCP, especially for our many colleagues who have been redeployed to unfamiliar roles in unfamiliar settings.
Thankfully, there is help out there! HSCP can and should harness the potential of online education and resource sharing to enable rapid upskilling.
A video on the correct donning and doffing PPE is presented and is essential viewing for all frontline staff. This video can be found on hseland.ie along with further guidance on hand hygiene and infection control.
For those HSCP deployed to manage patients in critical care and ICU, the Society of Critical Care Medicine provides a free online education programme: ‘Critical Care for Non-ICU Clinicians’.
The HSE Critical Care Programme has resources available online for staff being redeployed to Critical Care. These include an orientation manual and free online education modules. While these are designed for nursing staff, some sections are applicable and valuable to HSCP.
The Health Education England (HEE) e-Learning for Healthcare site also has a Coronavirus Disease Programme, which is now free to access without registration.
If you are looking for further clinical guidelines, the National Institute for Health and Care Excellence (NICE) has released a number of rapid guidelines and evidence reviews to support healthcare staff.
In addition, the HSE has launched a Clinical Guidance and Evidence repository for COVID-19. This provides a repository of the latest research evidence to equip clinicians in Ireland to respond to the coronavirus pandemic. It includes clinical guidance, evidence summaries and an online facility to request a rapid evidence review in relation to specific clinical questions regarding COVID-19.
Another central repository to be launched this week is from the National HSCP Office. This will enable a sharing of COVID and non-COVID resources with the intention of reducing duplication of effort for HSCP at this time.
Learning from the Italian COVID-19 Experience
As COVID-19 is a novel disease, there is huge value in connecting with countries like Italy, in the peak of the pandemic, to gain from the emerging learning there.
The Pediatrica Intensiva podcast gives a great insight into the Italian experience. It includes interviews with intensivists about the realities of managing the COVID-19 outbreak and caring for critically ill patients.
The International Society for Quality in Healthcare also has a webinar and podcast which shares the experience of Dr Francesco Venneri, a clinical risk manager and emergency front line worker in Tuscany.
These recommendations are not exhaustive and we welcome any suggestions you have on generalresources that could assist HSCP at this time. Please share using the comment box below.
Stay tuned for our next Blog on profession-specific on-line resources.
– this blog was written by Éadaoin O’Hanlon on behalf of the eHealth HSCP Advisory Group.