Consultant community geriatrician Dr Cindy Chu has been shielding since the end of March 2020. In this piece, she talks about what it was like working remotely from her patients, and how her team came together at lightning speed to put in place new ways of treating patients from afar.
Just before I started shielding on the advice of my department, I was looking into how we could support more frail older people at home on the Wirral in Merseyside, who may not have wanted to come into hospital during the COVID-19 pandemic.
The likelihood was that if they were to contract the virus, many of them may not survive it.
With the help of our microbiology, oxygen and pharmacy teams, we drew up a protocol very quickly for a Hospital at Home service (H@H) using our existing rapid response team from the community trust (led by Sarah Cowell) with provision of intravenous antibiotics, subcutaneous fluids, palliative oxygen and palliation as appropriate. Just a few days later, the service launched. Our teletriage team, end of life (EOL) team and community paramedic also played a major role in supporting the service.
It involved daily teleconference virtual ward rounds of the patients, with me making management plans as I would do on a physical ward round. I held telephone consultations when the nurses were at the patient’s home or care home, and liaised with families, having many realistic and EOL conversations as I would have done in person.
The challenge was not being able to examine the patients myself, but we got around that with good first-hand history (not needing to chase round for collateral history), clinical observations and blood tests.
Not being able to physically touch someone’s hand during a conversation has made me realise how much we rely on it to show our empathy.
We used our Health Information Exchange (which is part of the Wirral’s Global Digital Exemplar transformation) to obtain background information from the GP records and also any information on Cerner from previous admissions / clinic letters. I was also given access to Systm1 by the community trust which allowed me to access their records. My virtual documentation on Cerner is electronic and goes down the portal to the GP surgery. My secretary emails this to the H@H team to ensure that they have a copy and it is uploaded onto Systm1.
I was performing video consultations using Attend Anywhere. It was helpful as families were relieved to see that there is a consultant managing the care, albeit remotely, and that they were able to hear my explanation of the current situation. We also used Pando to share information, especially pictures.
We ran the service for 2 months which has been challenging as I was the only medical clinician and was working remotely, with only one prescriber on my team. We became busier as time went on and more people knew about the service. Soon enough we realised that as the patients were so sick, we had to continue ward rounds in the weekends and were working 12-hour days. This was unsustainable for all of us and we sadly had to pause H@H on 22 May 2020.
We had 149 patients come through our service with an average length of stay of 3.8 days. Only 10 needed transfer to assess (T2A) beds, and although some were admitted despite our input it was below the national average of 20%. Although some patients died, as expected in line with COVID-19, they died at home surrounded by family.
I am hopeful that our business case for more resource within this service will be approved quickly and we can recruit the team needed to restart the service soon.
Working from home has been interesting. Although it gives me flexibility, it is easy to keep going or to check the laptop at night or take more phone calls. Sometimes it takes physical effort to take a break or to switch off.
It has also been strange not to be able to have conversations in person with my patients and their families. Not being able to physically touch someone’s hand during a conversation has made me realise how much we rely on it to show our empathy.
It has been a huge learning curve for the entire team. The team has a much better understanding of frailty now and how to manage families’ expectations through all the discussions on our ward rounds and also witnessing me on my telephone / video consultations.
I do sometimes feel isolated from the rest of my department working from home, but overall I am pleased we had the opportunity to do what we did despite me being shielded.
COVID-19 has been a terrible experience for many people who have lost loved ones in the last few months. However, it has given us an opportunity to really evaluate how we do things and allow changes to happen without too much bureaucracy. It has pushed willing teams to work more closely together using creative methods of communication and sharing of information between different organisations. Our service would have taken months if not years of discussion for it to be considered and trialled, but in these circumstances, it only took a few days.
Working from home while shielding has been an incredibly interesting experience. Looking back, I’m amazed at the amount we achieved in such a short space of time, and I have to say that I enjoyed every moment of it. I am glad I have a very supportive department and colleagues (especially Dr Julie Langton) who looked after me even though I was at home, making sure I was getting time off and covering me during the days they made me take off.
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