Improving quality even in the hardest of times

When the pandemic hit, Shevaun Mullender, Head of clinical quality improvement, considered returning to her earlier role as a critical care nurse. But her quality improvement skills became essential for implementing the innovations the trust urgently needed.

Quality improvement is my main focus – especially improving patient flow. When Covid hit, I found myself sitting in the office thinking ‘Are quality improvement changes what we need most, when the whole world's going into meltdown?’ I wondered if, instead of managing improvements, I should put my scrubs on and return to being a Band 5 nurse.

I went to our medical and nursing directors and said: ‘I have a background in critical care and I'm ready to get stuck in!’ They suggested we try applying my QI skills to overseeing the unprecedented number of changes the ICU was about to experience.

Setting up our systems

The first stage involved making sure we had the right staff and space, and then upskilling the workforce. There was clearly going to be a lot of demand for intensive care, so all the elective care stopped. We set up pop-up training stations to upskill all the theatre workforce, and anyone else who was coming to help us from other departments.

I applied quality improvement skills to measure baselines and implement small cycles of change (Plan, Do, Study, Act). This helped us effect change incrementally and adjust it depending on results, so we could be really flexible and responsive to what the staff, the patients and the data was telling us. Throughout this period, I gathered insights from colleagues, mapped out project plans, and used driver diagrams and process maps to help the teams understand what we what we wanted to achieve, and how we were going to get there.

We developed different designs showing how the system could look, where we could surge into, where would be safe to work, and how we would access the medical equipment and personal protective equipment (PPE).

Changes to the ICU

One of the major changes to the ICU was in the ratio of staff to patients. In the past, we always had one intensive care nurse for every single patient. During Covid we moved to a model of one intensive care nurse overseeing perhaps three other nurses delivering care to three intensive care patients. The change was made because we had no other option. However, the outcomes were positive. Now, many trusts are reconsidering the way we staff intensive care units, to provide sustainable care for the longer term.

Another change was our pioneering work to transfer patients to ICUs that had more capacity (see Ronan's story). As the surge hit hard in Essex we were unable to move staff, so we opted for transferring patients to the sites that had most capacity. This process was extremely complex and technical, but we became experts at safe transfers. Nevertheless, there was still a huge pressure on beds – both for respiratory and intensive care patients. So, we started to look beyond the walls of our three sites to see what might help.

Virtual Covid wards

This thinking led us to the idea of virtual Covid wards. We knew a lot of ICU patients were stable but needed to wean off oxygen very slowly. We wondered if, for some, this weaning could take place outside of the hospital – still under hospital care, with support services, but in the comfort of their own home.

We already had a Hospital at Home team that helped with wound dressings or long-term antibiotics. So we met with them and the local community services to discuss options and agreed to pilot a jointly run virtual Covid ward.

Early tests produced useful learning. Patients wanted more face-to-face contact than we had planned for the first few days, to build their confidence. They also preferred phone calls to video contact. We kept adjusting things till we got it right.

Between January and March 2021, 146 patients were sent home with oxygen, and a further 48 for monitoring without oxygen, saving an estimated 1,552 bed days. Patients also provided overwhelmingly positive feedback, including:

Nothing to improve on – the staff were lovely and helpful, it was amazing.

Constantly kept in touch, very friendly and helpful.

I felt safe and well cared for under this service.

One surprise was that the patients weaned quicker at home than they would have done in hospital. We think this was because they were more mobile – making themselves cups of tea, for example – and perhaps more relaxed than they would be in hospital. So the scheme offered real benefits to patients, as well as easing pressure on beds, optimising discharge, and reducing clinical teams’ workload.

For me personally, that was one of the proudest moments of my improvement career: we really helped the clinical teams by freeing up precious inpatient beds and providing a safe, home-based option at this awful time, when they were so under pressure.

Changes for the future

Working in a crisis forces you to try new things that you may not try in normal times. Our work on virtual wards and patient transfer paved the way for similar work around the country. Many other changes that we made during the pandemic opened up new opportunities, too: we managed a major reset of our patient flow programme, won investment for different services, and employed lots of new people. All of these will have a sustained impact on how we work.

Now, we’re formalising our improvement work across our three sites. This includes engaging more of our colleagues in delivering changes – something people always find inspiring. This focus shows that we're a learning organisation, which in turn will help us meet our next challenge: retaining staff.

Going back to my initial uncertainty about whether quality improvement would make a real difference during Covid, I now know that the answer was ‘Yes.’ By systematically measuring changes and looking at outcomes, I helped colleagues see the benefits of their work and made sure we were pointing all our efforts in the right direction. It was a privilege to be part of.