COVID-19 has been the epicentre of a seismic shift in the way that we conduct our lives and has transformed how we work in general practice, possibly forever. What a shift it has been! Suddenly, we moved from seeing patients face-to-face, to managing all care over the telephone or via video consultation: an unprecedented move, and one that will echo throughout the NHS for years to come.
In line with NHS Guidance and Operating Procedures in the context of COVID-19 (NHS, 2020), practices were tasked with triaging patients remotely and patients suspected of being infected with COVID-19 were seen in a separate location to those without risk of infection.
Practices had a choice of how to deal with this. Every borough and practice chose to deal with the guidance in slightly different ways. We work in the borough of Lewisham and in a Primary Care Network (PCN)/Federation. This article describes how Lewisham and our PCN activated the local COVID-19 plan.
The hot hubs
April 2020 saw the development of two ‘hot hubs’ in Lewisham, at opposite ends of the borough, to which patients with a COVID-suspected diagnosis were referred. Our local primary care federation, One Health Lewisham with Lewisham Clinical Commissioning Group (CCG) took on the task of sourcing the two buildings at either end of the borough and upgrading them in order to be able to host up to 18 patients daily, including capacity for 6 patients who may need oxygen.
Transport in the form of a designated taxi service was provided to bring patients without transport to the hot hub, and if necessary to the hospital.
The two hubs were open from 2–6pm every day and every surgery in Lewisham could book any COVID-19-suspected patients into this clinic. A template was completed by the clinician at the surgery prior to booking the appointment at the hot hub, to assess the patient's risk and need, then if needed a taxi was booked to bring them to the hub to be assessed.
Once the patient arrived at the hub they were met by a member of staff and given gloves and a mask. They were then greeted by a nurse who took their oxygen saturation levels while they were standing and, depending on this result, they either walked to an oxygen bay or round to a clinical room to be examined by a GP.
The hot hub was managed by GPs and nurses from Lewisham practices who were released on a rota basis to staff this hub every day.
Our Primary Care Network
The new PCN in which we work, The Lewisham Care Partnership (TLCP), has a registered population of 58 000 patients across five practices. In December 2019 the partners at the five practices had agreed to work as one forming a PCN, which meant having one finance and HR system, and all partners agreed to share profit equally and become one larger organisation.
The Lewisham Care Partnership cold hub
Each PCN was able to decide how they would manage consultations for ‘cold’, i.e. low COVID-19 risk, patients.
In late March when the concerns about the growing effects of COVID-19 were beginning to mount, TLCP management team formulated a ‘cold hub’, a location where patients registered at all five surgeries without symptoms of COVID-19 and without exposure to the infection over the previous 2 weeks could be seen by doctors or nurses face-to-face in one location.
This involved allocating one practice site to be able to host all the face-to-face contact with patients both with the GP and the nurses. For the purpose of this article we are going to tell the nurses' story.
Development of the nursing team
The practice nurses from the five surgeries were asked to volunteer for the cold hub. This was based at St Johns Medical Centre in Lewisham. This was the largest of the five sites and the most central.
In total, six nurses and one health care assistant (HCA) from the five surgeries volunteered to work in the cold hub. Of the nurses who did not volunteer some were considered at high risk due to a long-term condition or age. Ethnicity risk had not at that time been realised. Involvement was on a voluntary basis and not all nurses reported a reason for not volunteering.
From the nurse team point of view, two nurses would provide a surgery from 9am–4pm each weekday with a break for lunch, training and meetings. There would be a named third nurse allocated each day for annual leave and sickness cover who may be pulled in from their home surgery if needed.
Those of us who agreed to be involved knew each other a little, having met at practice nurse forums, training and PCN meetings. We did not know each other well.
Early on we set up a WhatsApp group (with strict rules around patient confidentiality) to trouble-shoot problems that arose and we set up a weekly virtual nurses meeting so that we could all converge on a regular basis to iron out difficulties.
The nurses were given a short induction to the building and the IT system. An introduction letter was sent round via email to the nurses introducing them to the cold hub practice, including location of emergency drugs and emergency exits, as well as advising where stock was kept.
At this time, Public Health England and Health Education England went into overdrive and every day we would come to work to find something new to incorporate into our day. These changes would be delivered in a barrage of emails, and it was often hard to keep up.
The WhatsApp group was used to ask people to bring stock over, such as dressings and vaccines for baby immunisations. We messaged each other every day throughout the shift to ensure that we all were of aware of sudden changes. Communication was key here: it became so vital to the running of the hub and we worked hard as a nursing to team to maintain effective communication.
Setting up the clinics
Patients who needed to be seen face-to-face would be initially screened by telephone, text questionnaire or video streaming from the home surgery site by a clinician and if they felt it was necessary that they should be seen face-to-face, an appointment would be made at the cold hub by the home practice. Patients could not make these appointments themselves and the cold hub could not make follow-up appointments. Appointments could only be booked 4 days ahead.
Our appointments generally fell into three categories:
- Baby and childhood immunisation
- Dressings and suture removal
- Essential injections such as anti-psychotics, B12, contraceptive depo, gonadotropin-releasing hormone (GnRH) agonists (Zoladex, Prostap)
Vaccine ordering
Careful thought had to be given to vaccine management, and in the early days vaccine stock was transported to the cold hub from the five home surgeries with very careful attention to maintain the cold chain. Eventually we were given permission by Immform to increase the order ceiling for childhood vaccines directly to the cold hub. Our vaccine use was copious and three large fridges needed to be kept well stocked to keep us going.
This was an interesting moment as we have never spent so much money in 5 minutes! An order of £17 000 worth of childhood vaccines lasted us 12 days!
Learning points and actions
We needed to build a picture of our new vaccine usage and to ensure one of us was doing a weekly vaccine count in order to communicate early if a vaccine shortage was foreseen.
Dressing ordering
We undertook very large numbers of dressing changes and had to ensure we had enough stock to cover the patients from all five practices requiring dressings. We once again communicated over our WhatsApp group, and thereby sourced other surgeries' stock as we depleted the cold hub's stock.
Each practice has a central ordering system with a limit of £500 spend per order. We struggled to feed sufficient dressing stock into the cold hub with this system and initially had to request stock from each practice frequently.
Learning points and actions
In order to solve this we communicated with our dressing provider early on to request an increase in our maximum order value. This made it a lot easier to keep on top of our dressings stock.
Early communication over WhatsApp was very useful if stock was running low so we could ensure we did not run out.
IT system and appointments
The computer system was frustrating. We had to use a very slow, clumsy system in order to be able to access patient notes from each surgery. This was a central EMIS system which had a separate login to our usual one. It meant any one of the five practices in our PCN could book their patients into the nurse cold hub clinics. The biggest problem with this system was that it was very slow and cumbersome and froze frequently. Every time we switched between patients EMIS would shut down and re-open. It was not easy to look at Docman or print a T Quest investigation request form. Sometimes the patient's clinical notes would not link to their practice notes, so we could not see past medical history or previous consultations.
All of Lewisham GP practices had access to the appointment booking part of this EMIS system, as did other local cold hubs and our local General Practice Extended Access service. This meant that patients who were registered in practices outside our cold hub were sometimes inappropriately booked in to our appointments. There were also other errors in booking into the clinic. Appointments were sometimes double booked and inappropriate patients, for example those who should have seen a GP or those who could have been seen remotely, were sometimes booked in error. In addition, some of our less experienced nurses did not undertake all nursing procedures and inappropriate patients were sometimes booked to see these nurses.
We needed be very clear in our communication with the five home practices about which patients should be booked to the cold hub – we used the Royal College of General Practitioners (2020) guidelines for this. Ensuring GPs and the reception teams were clear about which consultations we could and could not undertake was challenging at times. One recurrent issue for example was ear syringing – this was a RED high-risk category procedure in the RCGP guidelines and we had been advised not to do this at our cold hub, but many ear syringing patients were booked in to see us by the home practices.
The telephone COVID triage screening that was supposed to be done by the home practice the day before patients attended the cold hub was not always documented in their notes by the home practices, so it was not always clear that this had been done, which increased our risk of potential exposure to infection.
Learning points and actions
Several times we sent a clear list outlining which patients could/could not be seen in the cold hub. This was circulated to home practices. We also sent a list of the cold hub nurses' skills to avoid patients being booked in with the wrong nurse.
It took us a few attempts to get the timing of our appointments correct with suitable gaps and breaks to allow our nurses to be able to clean the room between patients as well as be able to get a cup of tea if needed or visit the toilet.
The nurses were eventually given an extension to their smart card access to the IT system so that they could log-in to each of the five practices to make it easier and quicker to see patient's Docman letters and action blood tests. However, the EMIS system remained difficult to use during the life of the cold hub.
Personal protective equipment
The hot weather in June and July made working in personal protective equipment (PPE) exhausting. We were constantly dehydrated due to difficulties in getting regular drinks due to our masks and the heat of the consultation rooms. Good quality hand-cream for our sore chapped hands became one of life's essentials.
Changing PPE between patients was a trial, as was cleaning the room in between consultations. Eventually our lobbying of the management committee allowed us a catch-up appointment between every 3–5 patients so we were not running so late.
Learning points and actions
A key point has been to ensure we get constant feedback from nurses about how best to run the clinics with the least amount of stress possible. This information was taken immediately to the management committee and changes were made.
Staffing
This has been our biggest issue. We had six nurses out of the 10 who were able to see patients face-to-face and some of our staff were scoring as moderate risk on the Safety, Assessment and Decision (SAAD) score which meant they need to limit face-to-face patient contact (AMB Academy, 2020). We also had nurses from the black, Asian and minority ethnic (BAME) community working with us, which meant we needed to be mindful of their increased risk. This has meant the six nurses would only cover two clinics a week and no more; the idea is that another nurse would cover if a nurse was sick or on annual leave. This has proved to be a big problem as we did not have enough staff and practices were not able or willing to release their remaining nurses.
We were also very fortunate to have a trainee nurse associate working with us. She managed a lot of our dressings and B12 injections, which was a great help. We were also able to get some teaching done during her time in the cold hub, which was valuable for her course work.
As time moved on the team became tired and drained. The clinics were booked to full capacity and often beyond it. Morale plummeted as the long-term effect of running these clinics took hold. Donning and doffing, cleaning, working in extreme heat and out of comfort zones all the time, seeing new patients with different needs – such as psychotropic medications which some of the team are not used to giving – has had an effect. At least one clinical error/significant event has been reported by a cold hub nurse since April.
We are at time of writing considering going back to site level for all face-to-face appointments as we do not have the capacity to keep this system going unless we have more nurses to run it.
Learning points and actions
We are very early on in the process of creating our PCN family and working together as one body rather than the silos which general practices are very used to and comfortable with. COVID-19 has thrust change upon us without any time to contemplate or accept this. There has understandably been some resistance to sharing resources at times and this will be need to slowly worked on to try and bring about a change in mindset to see our five practices as one. This will take time and patience but if managed correctly we need to have a shared vision for our future to offer the best patient care by using all the local resources across our partnership.
On a positive note, this has enabled our nursing team to bond and work together. We aim to build on this to support each other, and to be able to give our nursing students a very different experience as we accommodate them between the five surgeries of the PCN on their placements, not just in one practice. We are now able to support each other as a wider team, using all our extensive skills and knowledge to nurture our more junior nurses in order to help them develop into the leaders of the future, and support them in their learning so they offer their patients a more rounded and detailed consultation.
We are working as a team on a long-term conditions pilot to manage our patients across the five surgeries, using the strengths of all the nurses and pharmacists employed by The Lewisham Care Network so patients can be managed and supported to the same high standard in each of the five surgeries.
Conclusion: what has COVID-19 done for us?
COVID-19 has made us work in very different ways, and catapulted us into the 21st century with new experiences in digital technology. It has begun to challenge the established way of doing things and to make us think about how we can work ‘smarter’.
We wrote this piece during the time when we were running the cold hub – we have been back in our own practices since July 2020. We, as a group of nurses from five surgeries, became bonded as a team during the life of the cold hub. We supported each other, shared ideas, and spoke up as one voice when faced with potential imposed systems or procedures we thought unsafe. We managed to treat a difficult and challenging time with good humour, were measured and professional in our communication with management, we were open to new ideas, learnt from each other and – best of all – supported each other through what was a challenging but rewarding experience.
KEY POINTS
- A ‘cold hub’, a location where patients registered at all five surgeries in the primary care network without symptoms of COVID-19 and without exposure to the infection over the previous 2 weeks could be seen by doctors or nurses face-to-face in one location, was set up
- Careful thought had to be given to vaccine management and dressing ordering in the cold hub and changes had to be implemented quickly
- Communication was very important – between nurses in the team, between the cold hub and home practices, and between the nursing team and management
- COVID-19 has challenged the established way of doing things and made primary care networks think about how to work ‘smarter’
CPD reflective practice
- How has COVID-19 changed the way the nursing team works in your practice?
- How have you overcome any challenges faced?
- Has this article given you any ideas on ways you could improve the way care is delivered for patients?