26 August 2020

As the World Health Organisation declared the spread of the novel coronavirus Covid-19 a pandemic and the UK went into lockdown, health professionals teaching at the University of East London started to investigate how their skills could be redeployed to support frontline healthcare workers.

Mike Gara, lecturer in physiotherapy, looks back at how members of the University's School of Health, Sport and Bioscience (HSB) stepped up to volunteer in the fight against Covid-19 and how he developed prone-position training programmes for staff at the NHS Nightingale Hospital London.

I arrived at UEL in September 2019 having previously worked as a specialist respiratory physiotherapist in the intensive treatment unit (ITU) at Queen's Hospital Romford, part of Barking, Havering and Redbridge University Hospital Trust - which would turn out to be one of the hardest hit trusts in London."

    Mike Gara, UEL physiotherapy lecturer and proning pioneer, said.

Then, the call came from NHS London. The world's largest ITU was set to be built inside ExCeL London, one of the UK's biggest convention centres, which would be transformed into the UK's first - and largest - NHS Nightingale Hospital.

Health Education England contacted NHS trusts and higher education institutions to ask for support with creating a staff training programme to upskill the personnel that would be needed to staff an ITU with a potential capacity of 4,000 critical-care beds.

Jane Perry, Dean of the School of Health, Sport and Bioscience, asked if staff would like to volunteer to help. As a school that teaches critical care nursing and physiotherapy and as staff are required to maintain their professional registration with either the Nursing and Midwifery Council or Health & Care Professions Council respectively, staff were ideally placed to provide teaching for the NHS Nightingale Hospital London.

Physiotherapy programme lead Liz Nicholls and Rob Waterson, programme lead for degree apprentice nursing, were the first two UEL staff members to offer up their expertise for the project. Ms Nicholls took on the role of non-clinical workforce lead and Mr Waterson as education faculty coordinator. Stephen Thompson, senior lecturer and programme lead for adult nursing; Harry de Jesus, lecturer in adult nursing; Daniel Perez-Martin, lecturer in adult nursing; and Mr Gara subsequently joined the team.

Educating the workforce quickly posed two major challenges, with two of the most important resources, ITU skilled personnel and time, both in limited supply.

"This meant we had a lot of content to teach in a short space of time. To assist with developing teaching, a classification system was developed based on how much experience a volunteer was anticipated to have - red (no healthcare experience), orange (some healthcare experience but not easily transferable), green (extensive healthcare experience and could fulfil a role in ITU with key skills training). Training was further divided into essential skills and colour code specific."

In ITU, an intubated and mechanically ventilated patient is normally cared for in the supine position (on their back) with periods spent in partial side lying to alleviate pressure sores. However, in extreme cases the patient may be nursed in the prone position (on their front), he explains.

Prone positioning is usually used as a last resort when a patient is approaching the capacity of the ventilator to provide adequate oxygen to the lungs. By placing a patient on their front and using pillows under their chest and pelvis it is possible to alter the patient’s respiratory mechanics by alleviating the pressure exerted on their thoracic cavity by their abdomen - this alteration rapidly increases the capacity of the ventilator to deliver adequate oxygen.

"This made it a potential life-saving treatment for Covid-19 patients as it prolonged the efficacy of the ventilator and in turn gave the patient more time for their body to fight off the virus. Despite this, it is a high-risk procedure with many potentially life-threatening complications if not done correctly," Mr Gara says.

According to Mr Gara, a patient can be nursed in the prone position between 12 to 16 hours before they must be returned to supine (de-proned) to limit pressure damage. Approximately 50-80% of patients with Covid-19 who required mechanical ventilation also required proning. It requires a minimum of five people (usually seven) to turn a patient from supine to prone (one anaesthetist and four others) and takes approximately 40–50 minutes to complete one turn.

During the pandemic NHS trusts were training specific proning teams to accommodate the large number of patients needing to be proned, he says. At Nightingale the team was anticipating a much larger capacity of patients and as such much larger numbers needing proning than at individual London trusts.

"Working on a worst-case scenario (that we would need all 4,000 beds) it was estimated that NHS Nightingale would need approximately 160 proning teams and, if we used a five member per team model, more than 800 staff just for proning."

As this would not be possible, Mr Gara wrote a standard operating procedure (SOP) based on a three member per team model.

However, this meant the proning teams would need to source extra members for every turn. To accommodate this, two training programmes were established - basic proning training and specialist proning training. The standard operating procedure also outlined specific responsibilities for all staff involved in proning to streamline the process, he explains.

The SOP was split into three stages: pre-prone, the procedure and post-prone. Checklists were created for all three stages to act as prompts for staff and ensure each stage was completed as efficiently as possible. The training programmes were then created to support these stages.

The basic training programme was a single session of 15-minute duration, mandatory for all staff working in the Nightingale hospital regardless of level. "This session did not aim to turn staff into experts - its main focus was to enable staff to be confident with assisting a turn but nothing else.

"This meant that every member of staff on the ITU floor was able to assist in turning a patient with minimal training. This was deemed an essential skill and so all volunteers had to receive this training. By the time the Nightingale closed, approximately 2,700 volunteers had been through the basic proning training. A video was created of the proning training which was shared online to provide additional support to volunteers."

The specialist programme was a half-day training session for registered health professionals with manual handling experience. The aim of the specialist programme was to create 'proning leaders' whose sole job in Nightingale hospital was to lead the proning teams.

The course aimed to develop confidence, leadership and team building through practice, discussion and reflection of a combination of scenarios and simulations. Physiotherapists were integral to the success of this programme - outpatient physiotherapists possessed the manual handling experience, leadership and team working qualities, but also found themselves out of work whilst their clinics were suspended.

"A key concept of the Nightingale hospital was reducing cognitive load - we were expecting a high-pressure battlefield hospital scenario where everyone would be stretched to their limits - therefore reducing the opportunity for mistakes was of the utmost importance, whilst still making everything quick and efficient so all patients received the highest standard of care we could give them."

A pre-proning checklist helped the ITU nurse, who had overall responsibility for four patients (usually one-to-one nursing in ITU) to ready patients safely and quickly; the proning lead would oversee the pre-proning procedure and countersign once they were happy the checklist had been completed.

The proning lead would then take over and organise the staff into position - once ready the anaesthetist would give the turning commands whilst protecting the endo-tracheal tube that connected the patient's lungs to the ventilator. The proning lead and the anaesthetist would then complete the post-proning checklist, to ensure the whole process was quick, safe and secure.

According to Mr Gara, the structure allowed for a scaffolded approach to learning, building on the existing skills of outpatient physiotherapists and transferring them into the ITU. This created a pyramidal structure where those who were more knowledgeable provided support and leadership to less experienced staff and ensured that a short 15-minute training session would be enough to provide adequate training to be effective.

"This meant that the proning teams could call on any staff member on the ITU to assist with the procedure so they never found themselves shorthanded. This approach not only protected the inexperienced staff, some of whom had no clinical experience, but also reduced cognitive load on all staff involved, particularly for the ITU nurse and anaesthetist who both had large numbers of responsibilities other than proning. A large number of these turning procedures were completed at NHS Nightingale - no complications were reported."

To further support the proning training, a ‘train the trainer programme’ was established early on. This was important to get all the volunteers through, he says, but also to support faculty staff as training was conducted seven days a week and many faculty staff were having to self-isolate with symptoms of Covid-19.

The first person to be trained as a trainer was Stephen Thompson, closely followed by his UEL colleagues Harry de Jesus, principal physiotherapy lecturer Barbara Catwell and Shan Howes, a senior lecturer in physiotherapy.

"Overall, this was a challenging project that required novel ways of thinking to find pragmatic new solutions. A cascade of knowledge approach meant that expert knowledge was disseminated quickly and safely to rapidly consolidate what was for many a new skill. All the volunteers (frontline and supporting) were nervous about what might happen at NHS Nightingale, but everyone committed to providing the highest standard of care we could."
Professor Amanda J. Broderick, vice-chancellor & president, said, "The work of these colleagues is a perfect example of how the whole University of East London community has risen to the challenges of these unprecedented times. The remarkable work done by these volunteers underlines our values of passion, courage & inclusion and how we remain an anchor institution throughout east London."

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