Inside the Nightingales

The Nightingale hospital in London may be due to 'hibernate', and the others unlikely to reach capacity, but doctors involved say the experience of creating a hospital from scratch has given them invaluable lessons. Peter Blackburn reports
Location: UK
Published: Tuesday 5 May 2020
London, Nightingale hospital
Consultant in emergency medicine Gareth Grier

One ambition was clear for Gareth Grier when he became involved with the Nightingale hospital at the Excel centre in London: ‘This is not a factory for patients to sit on a ventilator.’

As with everyone else, Dr Grier, a consultant in emergency medicine and pre-hospital care at Barts Health NHS Trust, was aware of the headlines and the dominant narrative; up to 4,000 beds under the high roof of an echoing conference centre – a vast space to house the sick for whom London’s hospitals were too swamped to care.

However, for Dr Grier (pictured), building a new hospital from scratch – and one that could end up dealing with huge amounts of patients in need of the most serious care – was an opportunity to ensure care and compassion were placed at the very heart of the COVID-19 crisis.

While headlines about NHS demand and daily deaths might be the order of the day, the patients and families touched by this deadly virus would not be left to feel totally alone and helpless, and the staff looking after them would know they were doing everything they could in medical and pastoral care. What Dr Grier and his team have already achieved is, perhaps, as remarkable as the efforts of those who physically built this hospital from the ground up.

‘If I’m honest, I didn’t really have a definition of compassionate care when we started this,’ Dr Grier says. ‘But one of the palliative care consultants described it as the care of the patient as an individual not a number and when we talk about the Excel having anywhere up to 4,000 patients that becomes even more important.’

Specialist team

Dr Grier brought together a team of staff – some doctors left without much of their existing work, nurses involved in trauma and injury and volunteers used to dealing with the aftermath of major disasters – to provide the most comprehensive communication between doctors, patients and relatives possible. In April 10 people were on shift during the day, and two at night, with scaled-up plans for shifts of 25 people should demand increase.

Families visiting patients is facilitated wherever possible, particularly when patients are approaching the end of life, rather than ruled out as many areas have felt forced to do, and families are called every 24 hours with updates or whenever conditions change seriously – including during the night if necessary. One patient was even baptised before passing away.

Dr Grier, who was watching a triathlon the last time he was at the Excel centre, adds: ‘The Nightingale was a clean slate for us. We know in many places family are not getting calls and we said let’s work to a gold standard we would like to achieve. If demand grows significantly it will be difficult, but we have plans in place to continue this for the first few hundred patients.

‘It is really rewarding. But many families are passing on their thanks and it’s become quite satisfying. It has to be good for clinicians too – if we can take that load off the clinicians on the shop floor while allowing them to know families are being communicated with it probably helps to deal with the tragedies.’

The Nightingale is at far from capacity – we may very well hope that it remains so – but the doctors working there also see it as an investment in the future too. Every patient requiring care at the hospital provides an opportunity to learn about a new disease and to attempt to understand how it will affect the country in the future.

Bypassing bureaucracy

Ami Banerjee associate professor in clinical data science

Ami Banerjee, associate professor in clinical data science at University College London and academic cardiologist (pictured), had already had a significant role in the coronavirus crisis – delivering statistics and  analyses which suggested the requirement for strict action to the chief medical officer, contributing to the Government’s decision to enforce lockdown measures in March. He was then seconded to help the clinical informatics team at the Nightingale hospital, as well as working there as a doctor.

And Dr Banerjee says the chance to build a good electronic patient record from scratch – without much of the interferences of usual NHS barriers and bureaucracy, a commonly enjoyed theme among doctors working in Nightingale hospitals around the country – is of ‘enormous’ interest and importance.

‘Our remit is to try to make the electronic health record as easy to use as possible so that the data we have is high quality and usable for all of the extensive audit and quality improvement monitoring we need to do. [If the crisis gets worse] this hospital could be the biggest intensive care facility in Europe if not further afield. We need to get this right.

‘This is a disease we know very little about. We are trying to gather information and knowledge that will be useful here and then elsewhere in the country.’

Dr Banerjee adds: ‘It’s scary and exhilarating at the same time in equal measure – you wonder how the hell have we got here, that we are doubling and trebling intensive care capacity in a first-world country? And why didn’t we take heed of warnings? But the other side is genuinely moving that on the clinical side, the informatics side and the research side there is a level of speed, collaboration and working together that is incredible. I have not come across anything like that in 18 years as a doctor.’

The London Nightingale treats patients in a 42-bed ward which is divided into bays of six. It is staffed by healthcare professionals with a wide range of expertise – some of whom have intensive-care experience and others who don’t, such as GPs, obstetricians and research doctors. Intensive care and anaesthetic consultants are the senior decision makers.

Staffing levels

Other staff at the hospital, who did not wish to be named, told The Doctor that the process of setting up the hospital had been remarkable – and those involved were all overwhelmingly positive and supportive, but had concerns about staffing levels and the unwillingness of some London trusts to release staff who had volunteered, as well as the capacity for them to do so with so many COVID-19 cases in their hospitals.

Those concerns would become more severe, they said, should the Nightingale be needed to treat many more patients – and could potentially lead to unsafe conditions. Some staff also raised concern about lack of adequate water supply for treatments such as dialysis and poor provision of facilities such as toilets.

Staffing, in particular, appears to be a significant issue. The NHS is significantly understaffed in normal times and finding the numbers that would be required should these new hospitals be needed in greater patient numbers could be a major issue.

Dr Banerjee says: ‘It is very much on people’s minds here… We are really stretched as a system and now with other Nightingale hospitals this is going to be an issue everywhere. We have had chronic shortages and we have not valued doctors and nurses as health professionals in the way that we should.’

There have also been concerns about the NHS’s transparency around the London Nightingale hospital in particular. A number of frontline staff told The Doctor of their desire or willingness to speak about their experiences and involvement but the hospital’s media team said it did not have time to ‘facilitate’ interviews and then failed to respond to a request for further clarification and reconsideration. The Doctor heard that some members of staff had been told they could not speak to the media, whether their experiences had been positive or not.

There are also Nightingale hospitals in Birmingham, Manchester, Harrogate, Bristol, Sunderland, Exeter, Glasgow, Cardiff and Belfast, with capacity for thousands of beds should the COVID-19 crisis escalate or peak again.

Overspill

Paul Glover is the lead intensive care consultant at the Belfast hospital which was set up in a tower block on the site of the Belfast City Hospital. The facility has 11 floors – with nine suitable for possible patient care and a maximum capacity of around 230 ventilated patients. At time of writing there had been up to 26 patients needing care at any one time.

‘It became clear that critical care capacity across the region wasn’t going to be sufficient for the model numbers,’ Dr Glover says.

Dr Glover and colleagues drafted in staff from medical and surgical specialties which had decreased workload and immediately arranged basic critical care training. They split doctors into ‘pods’, each led by an ICU consultant and each with an anaesthetic consultant and trainee and a consultant and trainee from another specialty with staff working 12-hour residential shifts with blocks of time on and blocks of time off.

‘It has been challenging,’ Dr Glover says. ‘These are different ways of working and the other specialties have had to learn a lot very quickly.’ A finite number of staff also meant moving from the one intensive care nurse to patient ratio to one intensive care nurse supervising three nurses and three healthcare assistants. Dr Glover says the system has worked well – with demand lower than expected and outcomes better than expected, but the plans and structures built will remain ready should they be needed.

‘Will we see a rebound? We have to be prepared for that. We have to have the flexibility to scale up whenever surges come and then scale down as quickly as possible.’

Diary of a doctor

Niall Eames consultant spinal surgeon

Niall Eames (pictured) is clinical director and consultant spinal surgeon at the Belfast Health and Social Care Trust and volunteered to take up a role in the Nightingale hospital – taking on his first 12-hour shift in years.

Mr Eames wrote a diary detailing his first seven days in the voluntary role: he worries about his mask not fitting tightly enough, his ankles and feet feeling vulnerable uncovered by scrubs and feeling dirty despite washing his hands seven times in 15 minutes.

He goes on to describe the high fives celebrating a stable patient, sleeping in his isolation room away from family, and the endless donning and doffing of PPE.

‘It seemed very daunting at the outset but it just felt like the right thing to do with the whole country in the middle of the pandemic,’ Mr Eames says.

For Mr Eames there have been lessons, as there will have been for so many staff in testing times: long shifts wearing PPE are exhausting and learning new expertise is unfamiliar areas is always challenging – but the opportunity to do so and see the work of other colleagues has been ‘inspirational’.

He says: ‘The amount of care and compassion and team working I have seen has been astronomical. It’s amazing to watch. I haven’t seen anything like it in my years in the health service.

‘Critical care, particularly with the PPE, can seem like a very clinical, uncaring atmosphere, with only a pair of eyes being visible, but the amount of care given to these people and the respect given to their dignity and health is amazing. These staff are such skilled individuals looking after people as best as they possibly can.

‘Personally, it’s been uplifting to be challenged in a way I never thought I would be – and fantastic to see the ability these staff have to make a change to people’s lives.’

The transition to working in intensive care is difficult, though, Dr Eames says.

‘It is a hard thing to go through. It has been strange just seeing my colleagues’ eyes. I just keep thinking what it must be like for patients to see us and be there. It is an eye-opening experience.’

Can-do attitude

Nightingale hospital, London

Across these hastily erected Nightingale hospitals structures and systems have been very different to normal working life – with flat hierarchies and ‘can-do attitudes’ and a significant decrease in blockages and bureaucracy. Several consultants told The Doctor that a simple computer tweak might result in a negative response that took six months to arrive, but anything required was being carried out more or less instantly now.

Those lessons learned have been almost unanimous in the conversations The Doctor has had with staff: this crisis has shown staff are willing to go to great lengths when the system unites in a common cause, that great things can be done without competition and strangling hierarchies and that clinicians, working together, can provide genuine care and compassion amid crushing crisis.

Mr Eames adds: ‘We are being forced to work in the best, fastest way possible for the patient ultimately. We need to translate that into normal practice.’

BMA council chair Chaand Nagpaul says: ‘The NHS has shown its remarkable qualities at every stage of this crisis – staff have worked under relentless pressure to protect the public while also taking on different, unfamiliar, roles and transforming services.

‘It is laudable that doctors have shown unparalleled leadership and drive to do good within a national calamity while also displaying the sheer care and compassion that has become so familiar to members of the public. Doctors have been remarkably adaptable and many have taken on roles and responsibilities they would never have expected – or desired – before this crisis.

‘But these stories should also serve as warning to the Government. We came into this crisis with proportionally fewer doctors and fewer intensive care beds than our counterparts in the EU – and with an entire health and care system hamstrung by years of austerity.

'Never again should this country be in a position where NHS capacity is so stretched that we must build intensive care units in tower blocks and conference centres, where cancer treatments are paused or where patients suffer serious illness at home rather than attending hospital. It is vital the NHS is properly protected, properly supported and properly resourced.’

Staff pride

While the Nightingale hospitals have not yet been called upon to provide care for the sort of numbers the scientific advisers predicted, the future remains uncertain. Another peak, a surge in cases, a period of calm – who knows? One thing that is not uncertain is the overwhelming sense of pride staff feel to be involved – seeing the work of their colleagues and the efforts of managers, clinicians and staff of all areas in uniting against the coronavirus threat.

‘It’s been an inspirational process,’ Dr Glover says. ‘People have just stepped up to do whatever has been asked of them. And there has been a whole army of people who have worked hard to facilitate this.’

Mr Eames adds: ‘We haven’t just found these heroes – they have been here all along, but we are recognising them now and that is so important.’

The staff in London are equally proud – none more so than those who wished to speak out but did not feel they could.

Dr Grier says: ‘I think this is the most extraordinary thing I have ever done. The huge thing here has been the team – this all sounds cliched but you walk through the Nightingale and you have such a strong sense of the cleaning teams, the porters and security guards right through to clinical staff. We are all in this together and that’s not something I have experienced in the NHs before.’

Dr Banerjee adds: ‘To see this place go from a basically empty conference warehouse to a site where we are taking patients is amazing. This is not where anybody wants to be. Nobody got out of bed and said this is what we want – but everyone here is happy to do it. I am surrounded by the most inspirational colleagues.’

The future is indeed uncertain. But staff are steadfast. ‘I feel exactly the same as everyone – nervous and anxious,’ Dr Grier says, ‘but I am pretty determined that the bigger this gets the more energy and effort we will put in to make it right. I think we have the foundations.’

While those coming days, weeks and months could bring anything, this process has proved already that the desire and willingness to go above and beyond in the NHS is unparalleled.