Coping with the heavy Covid hospital workload

By Dr R Neerunjun Gopee

For some time now, shortly after the beginning of the surge in Covid cases that has resulted in a rush for medical treatment, the public hospital service has been overwhelmed by the largenumber of admissions. This has put pressure on the hospital staff, nurses and doctors in the first place because they have the direct responsibility of attending to the patients. But also on other frontliners like domestic and other personnel such as in the laboratories, the blood bank -in short on all those manning supply chains, logistics, the multiple service requirements, and human resources that eventually converge on one objective: delivering care to the patient.

Because of the sheer volume of additional tasks that have to be carried out for every single patient, the already strained nurses and doctors have been facing tremendous pressure. As it is, there is a fixed numberof fully qualified personnel, and they can only give so much time to individual patients. The reasons are evident: they have to work on shifts, they need enough rest and recuperation so as to be to be in an optimum stateof bodily and mental health to perform their duties. They also have to be quarantined as per protocol. Besides, a number of them have fallen victims to Covid-19, leaving their colleagues in constant anxiety and fear of being similarly affected, with all that this means for their concerns about family and children if any – like any other citizen who is living through the same apprehensions.

It is no surprise therefore that the major complaint from both patients who have fortunately made it and from relatives of those admitted is the relative lack of attention and of communication on the part of nursing and medical personnel who are responsible for their treatment. We can look at what needs to be done for these inpatients in terms of: nursing care, medical treatment, and TLC or Tender Loving Care. As far back as over 40 years ago when I was training in the UK, not infrequently there would be a referral from a general practitioner reading: ‘please admit for TLC.’ These would be elderly or destitute people with co-morbidities, not necessarily of an urgent nature – but who had nobody to care for them.

Many complaints from relatives about their near and dear ones admitted in the Covid wards have been about the lack of TLC, besides the lacunae in the nursing and medical aspects. About the latter, there has been the issue of the unavailability of drugs and latterly of oxygen which seems to have been addressed as a matter of priority. But in medicine, alas, everything is a priority!

Briefly, the nurses have to ensure that they have the adequate amounts of medicines (which they have to collect from the hospital pharmacy daily) and the other medical supplies such as syringes, IV sets, etc.; general ward supplies such as bedding, and maintaining cleanliness; dispensing medicines and other treatments (e.g. injections) prescribed by the doctors; observing and recording vitals such as temperature, blood pressure and other parameters on bedside monitors; personal care such as cleaning and bathing patients which become more onerous and complicated when they are bedridden or otherwise unable to do their minimum for themselves, etc.

Besides prescribing treatments, especially in ICU settings doctors have specific and highly sophisticated tasks to perform in terms of monitoring vital parameters with the help of complex apparatus, caring for intubated patients, keeping watch on IV lines so they do not get blocked and changing them as needed, recording findings so as to monitor evolution of the diseaseand many more acts. And a key measurement in serious Covid patients is 24/7 monitoring of oxygen levels.

On top of performing all these tasks, both categories are expected to deliver TLC, which even under normal circumstances there is little time left for.

The usual response of the authorities under such circumstances has been to recruit retired nurses and doctors. This is not the best option for several reasons. To start with such recruitment is not as rapidly done because it needs to go through the PSC; additionally, most of the retirees are not really keen on going back: they are looking forward to enjoy their retirement, and have enough means to do so what with children if any who are settled and on their own, and thus they have fewer responsibilities and their needs also are reduced.

One measure is to recruit from overseas, which has been announced: about 75 staff comprising specialised nurses and intensivists (doctors specially tried to work in ICUs) are being sought from India, the eternal giver and source of succour when we are in deep trouble!

However, there is one option which merits serious consideration to palliate the gap and which can be rapidly implemented – that is the induction of final year student nurses and interns or doctors undergoing pre-registration training, especially those nearing its completion. When India was facing the acute surge of Covid and frontline personnel was a problem, Dr Devi Shetty, well-known Paediatric Cardiac Surgeon and Founder of Narayana Hrudalaya in Bangaluru had suggested the induction of final year medical students to help in looking after Covid inpatients. I do not know if his recommendation was taken up but it is certainly very plausible and feasible.

The student nurses could carry out several of the nursing tasks under the supervision of the qualified nurses in charge of the wards/ICU, who would be freed to perform their other duties. The pre-registration doctors who are young, energetic, IT savvy and eager to learn would be a tremendous asset in doing monitoring especially in ICU which is usually under the responsibility of a single anaesthetist who cannot be everywhere at the same time!

It must not be forgotten that as well as catering for Covid patients, hospitals have also to run all the other services as well, and they make up the bulk of the workload. Further, this posting in Covid wards represents not only a serendipitous opportunity for these two groups to hone their existing skills and learn new ones, but will also make them acquire hands-on experience in the management of acute cases. Besides, more likely than not, there are surely going to be questions on Covid in any future examination. There is therefore the additional advantage of quasi-effortless and live updating on all aspects of the disease simultaneously, which will help immensely in answering questions, in particular during orals if any.

Implementing this measure – of inducting senior nursing students and pre-reg doctors – can be done through a policy decision in consultation with the respective Nursing and Medical Councils, whose Acts make provision for contingency and emergency situations. But these nurses and doctors must be provided an incentive as motivation. Dr Devi Shetty had suggested that internships could be reduced by a certain period, say three months. Here, the nurses and doctors could be granted upfront a certain percentage of marks for their exit examinations, say 20% which I think is quite reasonable.

As for TLC, why not consider allowing relatives to be in attendance at specific time slots to perform some of the more delicate tasks that require respect of the patient’s intimacy, such as bed bath and changing diapers, feeding, shaving, etc. They would do it with care and love, and give the comfort and moral support that the nursing and medical staff would love to give too, but are simply too overburdened with more technical tasks to be able to fulfil.

The relatives can be suitably briefed, and I am sure they would comply with whatever instructions are given as I can vouchsafe from my personal experience in the public service, though under different circumstances. But I know my fellow Mauritian parents and relatives of severely ill patients I have had to look after, and the solidarity of the nurses with them at such moments is amazing.

The result of such a policy decision can bring tremendous relief to nursing and medical staff, patients, and relatives.

Where there is a will, there is a way.

* Published in print edition on 30 November 2021