key: cord-0287583-2o1mvkcj
authors: Achat, H. M.; Mittal, R.; Stubbs, J. M.; Gilroy, N.; Schindeler, S. K.; Shaban, R. Z.; Solano, T.
title: Managing COVID-19 in an Australian designated isolation facility: Implications for current and future healthcare crises
date: 2022-05-07
journal: nan
DOI: 10.1101/2022.05.05.22274702
sha: a9410897f4ccaeda71daff1e8a1f3966bb4f0467
doc_id: 287583
cord_uid: 2o1mvkcj

The lived experiences of healthcare workers (HCWs) and their perceptions of the pandemic can prove to be a valuable resource in the face of a seemingly persistent Novel coronavirus disease 2019 (COVID-19) to inform ongoing efforts, as well as identify components essential to a crisis preparedness plan and the issues pertinent to supporting relevant change. We employed a phenomenological approach and using purposive sampling conducted 39 semi-structured interviews with senior healthcare professionals who were employed at a designated COVID-19 facility in New South Wales (NSW), Australia during the height of the pandemic in 2020. Participants comprised administrators, heads of department and clinicians. We obtained from these HCWs (i) perspectives of their lived experience on what was done well and what could have been done differently and (ii) recommendations on actions for current and future crisis response. Four themes encapsulated insights of respondents that should inform our capacity to meet current needs, direct meaningful and in situ change, and prepare us for future crises. Observations and recommendations of respondents are informative for decision-makers tasked with mobilising an efficacious approach to the next health crisis and, in the interim, would aid the governance of a more robust workforce to effect high quality patient care in a safe environment.

Introduction boarders [19] and strong collaboration among experts, by no means spared HCWs and the 67 public from the aforementioned challenges in early 2020. As all countries come to terms with 68 a seemingly inevitable 'COVID normal' state of operations, the lived experience and 69 perceptions of HCWs who held senior clinical and administrative positions during the 70 pandemic can prove to be a valuable resource. Frontline responders' unique insights into 71 health care delivery can enable discernment of aspects of health care and its coordination that 72 have been efficiently addressed, areas that prove to be ongoing challenges, as well as reasons 73 for the situations encountered. Explicating the lessons learnt should galvanise decision 74 makers to meet current needs and identify issues relevant to a preparedness plan for future 75 crises. 76 The aim of this study is to document, through the garnering of lived experiences and This qualitative study was conducted using a phenomenological approach through individual 87 semi-structured in-depth interviews. Addressing the study questions "What could have been 88 done, or done differently to better respond to the pandemic?" and "What would you like to 89 see maintained as we move towards a 'COVID-19 normal' phase?", researchers aimed to 90 describe staff's perspective of changes in their lived experience at the height of the pandemic 91 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 in 2020 and their recommendations on actions that could facilitate their workplace's 92 response to COVID-19 and preparedness for future health crises. 93 Procedure 94 95

In-depth, semi-structured individual interviews were conducted in person or via online video 96 (Zoom), according to the participant's choice. The interviewers were three of the co-authors 97 all of whom were female and qualified and experienced public health professions. 98 Participants were asked a preliminary question about their roles prior to and subsequently 99 during the height of the pandemic, which enabled confirmation of their involvement in the 100 hospital's pandemic response. The interviewer then loosely followed a script that supported semi-structured interview with an expected duration of approximately 45 minutes and an 118 interview appointment. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 Radiographers Note: † denotes less than 3 participants; number not reported to maintain confidentiality 121 122 Data analysis 123 124 Interview audio-recordings were imported into a commercial program that produced a rough 125 transcription. The interviewer cleaned the initial transcript by assigning speakers to the script 126 and correcting text and punctuation.

Data were analysed using Colaizzi's distinctive seven step process [20] that provides a 128 rigorous analysis, with each step staying close to the data, which includes familiarisation, 129 identifying significant statements, formulating meanings, clustering themes, developing an 130 exhaustive description, producing the fundamental structure and seeking verification of the 131 fundamental structure. Researchers engaged in ongoing analyses. Transcripts were analysed 132 by at least two researchers using a standard template, before discussions with the wider 133 research team about emerging themes to inform the focus of subsequent interviews.

Following the transcription of the first few interviews, a review of the completed templates 135 by research team members confirmed persistent themes. The team was responsive and open 136 to what was in the data and allowed it to guide an iterative approach to analysis. Researchers 137 analysed the transcripts independently by bracketing data on preconceived ideas and strictly 138 following the Colaizzi method described above. Early analysis allowed the initial 139 development of a coding framework that underwent ongoing development as transcripts were 140 re-read and reviewed. Researchers reviewed emerging findings at regular team meetings until 141 data saturation occurred and used consensus to resolve disagreements.

A key to reading the quotes is provided below: 143 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The criteria of credibility, dependability and conformability [21] were used to confirm the 152 rigor of the findings. Following the transcription of the first few interviews, a peer review 153 process was used by the research team members to confirm persistent themes. We adhered to 154 all assumptions and strategies of the qualitatively driven designs. We were responsive and 155 open to what was in the data and allowed the data to guide our iterative approach to analysis. 156 We reviewed emerging findings during daily team meetings to ensure data saturation and 157 consensus among study team members. This was done to ensure the credibility of research.

This study was approved by Western Sydney Local Health District Ethics Committee 161 (2020/ETH01674). All participants received information about the study, and a consent form, 162 which they were asked to read, sign and return. They were made aware that they could refuse 163 to answer any question and could terminate the interview at any time. Our study adhered to 164 standard ethical processes for qualitative research to ensure the anonymity of participants and 165 confidentiality of the data. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Thirty-nine interviews were conducted via Zoom (N=35) and face-to-face (N=4). All 173 participants were employed in roles with a primary focus on the provision of health care in 174 the height of the pandemic. We obtained over-representation from the emergency department 175 (ED), intensive care unit (ICU), respiratory medicine and infectious diseases (ID) 176 departments including the COVID clinic and ward, which were deemed high exposure 177 environments. Twenty were in newly created roles working either on the COVID-19 ward or 178 in another capacity (Table 1) . Interviews had a duration of 30 to 104 minutes, averaging 60 179 minutes and were conducted from November 2020 to February 2021. The unknown characteristics of the virus, initially amplified by a plethora of information 184 from local and international sources, were a cause of heightened anxiety and stress. HCWs CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table 2 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. If we had a CELP [centralised equipment loan pool], or a centralised thing, if someone was in charge of maintaining that, we wouldn't have expired stock. (P02) b. Under the WH&S umbrella, enhance/maintain necessary infection control measures and training I don't think I've ever seen better hand hygiene in the hospital, wiping surfaces down, making sure that we're always keeping things clean and tidy, respiratory etiquette, coughing into the elbow, it's a really nice thing … (P27)

We made some substantial changes to clinical practice around here over that time that, going forward, you'd like to see maintained … we have all these protocols and procedures now… In the event of something else like this, we have to be careful we don't lose them, because they're all done and they all work … a greater awareness by staff on PPE use, and what's most effective with that. I think that's been really good. One of the hardest things from the very start, I felt, from a frontline staff health perspective, is … they had to staff it [the COVID ward] with in-house pool staff, or agency staff … And we've obviously learned as time has gone on that was not a good thing, because there was hardly any continuity of staff on each shift. There was no person put in charge of that ward [initially] … They desperately needed somebody on that ward to pull them together … (P36)

The change in visiting policy was [something] everyone struggled with very much, even me. ... When the visiting changed, the visiting policy was absolutely zero visitors. Especially when you had dying COVID patients -that was really challenging. A lot of staff were quite traumatized by that … We had, how many deaths? … In one family the wife was allowed in for half an hour, and in the other one [the patient] died alone. So that is … very hard for the nurses to accept. Well, everyone really … this is really against all our practices, our morals, our values. That was hard to swallow, but I guess it's the greater good, for the greater amount of people and it's to protect everyone. But … when you're so entrenched in your morals, values and how death should look, that was very hard to overcome. (P22) Keeping the visitor [numbers] small, because … unless there's a few special circumstances … generally, most people only need one person with them, or two max, and probably actually need to have a rest because they are sick. So just keeping numbers low, we'll probably continue that. (P04) e. Provide fit for purpose infrastructure to reduce transmission in hospital (e.g. hot zones, separate COVID clinic and ward, negative pressure rooms) I think the built physical environment is very critical. Just due to the nature of our work and the potential for airborne transmission. (P13) You need to understand better how to manage these airborne transmissible diseases in a hospital setting, and do it effectively all the time, not just because the pandemic has come around … it just makes no sense to me anymore to be 'cohorting' infectious patients together. (P11) So, we had to then reconfigure the emergency department and build a negative flow room. And then, how do you treat patients in these rooms? How do you communicate with them? How do you communicate with the staff? And how do you respond, doing your straightforward work, such as giving morphine, for example. That was a huge, huge task. (P34) f. Maintain processes and procedures that support infection control and WH&S Some good stuff came out of it [the pandemic]. We've learnt how to make special circuits for NIV for the infection-prone … NIV circuits that had expiratory valves on them, so that you could filter the air that was coming out. And that was quite big, because you have to change the whole circuit setup. There was a lot of work done by a few people to figure out how to have these safer circuits that we could use if we needed to … Stopping use of nebulizers, better controlled use of oxygen or high-flow oxygen, those were all important things. (P11) Theme 2. Maintain a sense of collegiality and informed decision-making a. Preserve teamwork and working out of silos as displayed during pandemic It was a great response in the end and I think everybody was happy to knuckle down and put in what was going to be required, recognising that it might involve a lot of extra work and time to deal with this problem if it gets out of control … a sense of 'well, that's what our job would be'. (P11) I think in a pandemic … as a hospital you come together, everyone's got one agenda … so you pulled together as a team, and that really occurred; everyone put aside their [own] agenda. (P24) [We] have an intensive care department and emergency department and anaesthetics department who all talk to each other now. It's actually changed communication. (P21) b. Acknowledge the contributions of all teams of healthcare workers For us, it was important to acknowledge staff for their work and effort, and it was an eye-opener how some people responded, and how much value they added. (P31) Now we're coming down to a normal period. I think it's also a time that staff can sort of receive that word of appreciation, that gesture of appreciation. (P09) c. Activate one source of information to reduce overload and excessive channels of information There's communication, and how you get communication to every tier of your organisation in a way that's consistent. The messaging has to be consistent … that is very important. We have what we hear on the TV, what we hear at a national level, what we hear at a jurisdictional level, what we hear at the hospital executive level then what we hear at an interdisciplinary meeting level. And I think one size does not fit all. I think one of the things we realized is that you have to take all that information and communication and adapt it to your local context. I think that's been very challenging ... (P10) I really struggled with the communications. It would have been good to have a dedicated staff member in the ICU that was doing nothing more than channelling and filtering and then sending out the information that my staff require. The amount of time that we all spent looking at the same emails, trying to figure out what was new, what was relevant, what was important … it would have been really good to have a dedicated staff member doing that … integrating information across all of those clinical groups at the coalface that was almost a full-time job for an army of people … that was done by clinicians. (P23)

If we just had one source of truth, I think it would be less confusing for people. (P10) There were issues with the use of different types of masks -P2, N95, normal masks. And because there's different information coming from the Ministry, different information coming from the CEC [Clinical Excellence Commission] that was always lagging behind … we almost felt that we were several steps ahead of the CEC, because CEC has to come up with a policy based on consensus … Yes, there was confusion, come to think of it. (P31) d. Provide timely directives developed through transparent, credible and accountable measures I don't know where they got that evidence from. And, you know, that wasn't communicated to us. A lot of these policies were … instigated overnight. And we just had to … implement them, with little or no consultation. (P22) Should have had some open forums or Skype forums where people could ask questions, because, while I knew what was going on, and the medical and ED knew, a lot of other people not in COVID wards didn't have a good grasp of what was going on. (P15) So … we called for hospital Q&A sessions … they have an ID consultant in there … and then at the end, it's [open for] questions. Just to assure the staff that this is happening, this is how we're going to deal with it. We're going to make sure that you guys are protected as a health care provider. (P32) Theme 3. Plan for future crises a. Retain skilled multidisciplinary emergency taskforce

There was a lot of confusion [not having enough staff] initially. A lot of anxiety and it slowed down workflow a lot. (P07) b. Implement written emergency preparedness plan with designated spaces and workforce I think preparedness is probably the biggest challenge. You never know what's around the corner. But to have contingencies in place, and to have a strategy that is not necessarily a tailored strategy, but it's a strategy that can act as a formula for a ready-to-go. (P13) And when you have an evolving environment and COVID as well, it creates a lot of extra stress and uncertainty. When staff come to work not knowing whether maybe in two weeks' time we might move from this place and move to somewhere else again. (P09) c. Determine criteria and plan for escalation/de-escalation of clinical operations [Staff] have been rundown and then what we're going to do is, as soon as things ease, we're going to ramp surgery back up, which I felt was a bit of an issue. … We could have stepped surgery back up in a clean, more controlled way. … I think the most frustrating thing is … there was no formal process of escalation.

We could have done [some preparation] prior to this pandemic, to some degree of how we would shut down services in a staged approach, where the priorities for staffing would be, activating flexible work plans, all that sort of thing. (P13) d. Deploy a multidisciplinary central control committee and a chain of command to facilitate communication, dissemination of information, and direct the review/development/update of guidelines, minimise the overflow of information and duplication of processes, and support guidelines appropriate to facilities' unique operations I still don't know what the hierarchy is, I report to all these different people. (P01) There is a risk assessment, what level we're on at the moment … at one stage, there's four levels to the risk assessment risk matrix that was developed here at [Hospital 2]. And then the CEC brought out a risk matrix with only three levels, and they didn't align. So we were often sitting on that line between green and amber. (P03)

Investigations are generally delayed … It was such an ordeal to clean all the machines that would investigate them, certain services wouldn't even investigate the patients until they were [COVID] negative. And so, a lot of the time … they weren't being investigated properly, they weren't being examined properly … They go to fuel inpatient stay times … other investigations … unnecessary treatment … huge follow-on effects. … You just go for days … until the swab came back negative … definitely delayed their scans by 12 to 24 hours depending on the swab time. (P07) Theme 4. Promote corporate and clinical agility a. Identify and protect vulnerable staff and patients to provide options, e.g. leave, redeployment, social support There are actually a lot of vulnerable healthcare workers around everywhere. For example, in my department, either older age, or some chronic disease, but they still work in the front line. I think they need to know, because of their risk, there's still a system in place for them. For example, if we need to relocate them to work in a lower-risk environment… (P09) b. Utilise alternatives to traditional team-based care to deliver quality care Their [Registrars'] regular training practices, their training clinics, their procedural lists were all thrown out the door with the ward-based system. I think one of the problems that we faced was that we felt that this ward-based system was thrust upon us. And even though there was limited consultation, I don't think there was any major consideration of the significant disadvantages of this system. … It was a real black and white, all or nothing approach where we transition to immediate ward-based care or normal team-based care. … We probably need to have a better consideration of how to stage our transition … without going from one to the other extreme immediately. (P30) "It [ward-based care] decreased the movement, but also made the patients in the ward a doctor's responsibility. So it led to earlier detection of problems and greater communication between the nursing staff and the medical staff, who knew what their patterns of communications were. So the doctors were more immediately available." (P06) c. Continue remote work culture that supports work-life balance (e.g. remote meetings and education where suitable)

If we run a big departmental meeting, we can also invite other specialities to join and they just log in. That's it. You know, attendance is amazing, CPD [continuing professional development] will be amazing for 2020. … The attendance at our departmental meetings is quite high because it's all Zoom … virtual meetings are easy to log on to. So, again, it's easier to invite other specialities. (P21) d. Apply technologies such as telehealth to enhance patient care where applicable A lot of patients prefer … telehealth because it's a big deal for some of our more frail or less mobile patients to get to the hospital, find parking, wait for their outpatient appointment, pick up their script. 

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101/2022.05.05.22274702 doi: medRxiv preprint 1(c) Equipping the COVID ward with a permanent nurse unit manager and staff eliminated 230 the daily task of training nurses from a temporary pool, and reduced time pressures on 231 clinicians as well as the anxiety of patients whose questions previously went unanswered at 232 best. Permanent staffing fostered teamwork and increased competency, valued in a highly 233 stressful environment.

And so, you train someone up, and they'll be gone the next day, you train someone else up, and they'll be gone 235 the next day … The patients they were helping would ask them questions, and they wouldn't know the answers. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. 

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101/2022.05.05.22274702 doi: medRxiv preprint 2(d) Transparency, credibility and accountability of timely directives were noticeably absent.

The initial lack of identified channel(s) of trusted information resulted in misinformation, 305 anxiety and inconsistent practices. Participants voiced concern about operational decision-306 making that sometimes lacked input from staff at the coalface.

One of the things that was potentially lacking was transparency with what was happening at the state level, 308 or within the Ministry of Health level, that appeared to be almost like a black box. (P06)

Missing from state directives was an appreciation that health facilities were not equal 310 pandemic responders and therefore directives needed to be specific and detailed.. 

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The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 3(a) COVID-19 demanded an urgent review of usual health care activities. Delays were 329 counterproductive to efforts to keep staff engaged. A taskforce that could be activated at a 330 moment's notice would minimise delays, staff anxiety and the accompanying risks to staff and 331 patient well-being. 

We should have had a pandemic plan. We have for influenza; we've had these plans … at an executive level 340 probably sitting on a shelf somewhere…. But it's not just about having a document as to how you do these 341 things … we've learned …we were doing things very reactively. But now, part of our mandate with the 342 biocontainment centre is that we're going to be thinking very proactively about pandemic planning, and at 343 every level… (P10) 344 3(c) The criteria and a plan for modifications to clinical operations, including escalation and 345 de-escalation of procedures, would enable staff to be prepared and act in unison.

We probably need to have a better consideration of how to stage our transition from a team-based or ward- CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101/2022.05.05.22274702 doi: medRxiv preprint I think there has been a very strong case for us to have some sort of strong national, multidisciplinary 355 communicable disease centre, where you incorporate all the leaders from these various groups into one 356 entity that could then share their information and make sure that all the information that they're sharing 357 with their groups is consistent. (P10)

Theme 4: Promote corporate and clinical agility 359 Staff and patient safety and well-being are paramount concerns for any health system. Changes from the medical staff model to your ward-based group, they should try and hang on to that, but 377 that's going to take some investment of resources. … That really made a difference. … But that's completely 378 changing the delivery of medical care…. (P20)

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The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101/2022.05.05.22274702 doi: medRxiv preprint 4(c) Technology offered the organisation an avenue to sustain aspects of workplace 380 requirements, as staff could remotely attend meetings, engage in educational sessions, review 381 medical notes and communicate with patients. The remote work culture was welcomed by 382 most, despite its sudden and widespread application.

It was a significant cultural shift for the entire organisation to realise that you don't need to physically be in 384 the building to be able to contribute. There's a role for physically walking around and seeing the lie of the For certain conditions, such as those requiring a physical examination or patient observation, 397 telehealth was deemed unsuitable.

We decided that there were very few visits that we could cut out, or that we could move to video. …we 399 needed to keep doing most of these visits as face to face visits, because to do otherwise was going to 400 potentially make things unsafe. (P38) 401 402 403 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 Minimising the contact between infected and non-infected patients and staff using 'shelter CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 7, 2022. 

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The copyright holder for this preprint this version posted May 7, 2022. Participants extoled the agility of staff as they reflected on efforts to achieve essential 488 elements for a responsive health care environment that provides quality patient care while Telemedicine proved effective in filling some health care gaps, enabling healthcare services 498 to infected and non-infected people during the pandemic.

[53] In our study clinicians had 499 mixed reactions to its sustainability, citing situations when a traditional physical examination 500 is necessary. Nonetheless, most appreciated that remote working has the potential to be cost-501 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 7, 2022. The present study focused on one facility that is a designated COVID-19 facility in Australia, 506 potentially limiting its generalisability. Our purposive sampling however, captured key 507 informants who were representative of crucial sectors of the pandemic response. They were 508 strategically placed to identify successes and gaps in the provision of health care, and to make 509 considered recommendations reflecting both a bird's-eye view and coalface experiences. This study presents, to our knowledge, the first report of lived experiences and 520 recommendations from clinical and non-clinical senior healthcare professionals in Australia.

Their observations and recommendations should inform decision-makers tasked with 522 mobilising an efficacious approach to the next health crisis and, in the interim, aid the 523 governance of a more robust workforce to effect high quality patient care in a safe 524 environment. Admittedly, the initial challenge rests with leaders who must agree to prioritise 525 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 7, 2022. ; https://doi.org/10.1101/2022.05.05.22274702 doi: medRxiv preprint fit-for-purpose systems and structures as part of crisis preparedness while simultaneously 526 tackling inexorable current demands.

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Advice for people at risk of coronavirus 661 (COVID-19) 2020

The impact of working from home during COVID-19 on work and life 664 domains: an exploratory study on Hong Kong

Telepsychiatry and the Coronavirus Disease

Pandemic-Current and Future Outcomes of the Rapid Virtualization of Psychiatric Care

Telehealth for 669 global emergencies: Implications for coronavirus disease 2019 (COVID-19)

Telemedicine, the current 672 COVID-19 pandemic and the future: a narrative review and perspectives moving forward in the USA. 673 Family medicine and community health

The benefits and limitations of telecommuting

Between-person and within-person effects of telework: a quasi-677 field experiment