Abstract

Last year the global community was confronted with COVID-19, a rapidly spreading pandemic disease. Hospitals had to cope with an increasing number of infectious patients, at times overwhelming their capacity. To prevent further transmission of the coronavirus, several protective measures had to be taken, such as the setup of large quarantine admission cohorts in hospitals, including in intensive care units (ICUs), and the use of personal protective equipment (PPE). The shear load of patients as well as these protective measures brought along certain difficulties for the staff working on the ICUs. Healthcare workers experienced problems in communication due to the mandatory strict use of PPE precluding easy access to cell phones and computers. Also, the increased workload restricted time for individual patient care. Hence, a different approach to the way we delivered our care was required. In this short report we describe the implementation of a student-managed command centre at Leiden University Medical  Centre, which was designed to reduce the workload of our clinical staff and to increase the quality and ease of communication.

Introduction

Since the outbreak of COVID-19 in Wuhan in late December 2019, the coronavirus rapidly spread to over 200 countries around the world.[1] We  were globally confronted with a new, unknown disease. The presentation  and severity of COVID-19 seemed to vary greatly between individuals, which  has mainly been explained by the presence of comorbidities,  including diabetes mellitus, hypertension, asthma/COPD and acute  respiratory distress syndrome. Recent studies have also shown that the risk  of unfavourable outcomes increases with age >60 years and that severe  disease is more common in patients with male gender and a history of  smoking or substance abuse.[2-5] Studies have reported ICU admission rates for hospitalised patients with COVID-19 ranging from 15 to 26%.[6-8] The care of critically ill COVID-19 patients is not without considerable challenges and requires a different approach to care. In this article, we  provide an effective strategy to tackle some of these challenges in the ICU, which was designed to improve work efficiency and communication of ICU healthcare workers.

Problems: communication and workload

To prevent transmission of the Sars-Cov2 virus, ICUs with COVID-19 patients are allocated to quarantine cohorts. Accordingly, healthcare workers entering these zones must wear PPE, including an FFP2 face mask, eye  protection, and a gown to protect themselves from contagion. These protective measures, however, lead to certain difficulties of which communication is the most important one. Due to potential transmission and principles of infection prevention, the use of pagers and cell phones is not allowed on the cohorts. Hence, communication on the ward, for example a nurse looking for a doctor or residents wanting to consult their supervisors, is difficult and may lead to a delayed response. In addition, communication from the quarantine zone with the rest of the hospital is hampered. Consultants cannot easily reach the doctors on the cohort and vice versa. In our experience, even arranging a CT scan became an obstacle, since doctors on the cohorts may have difficulty in interacting with the radiology department or using the computer workstation. Besides the difficulty in communication, the rising workload for ICU staff also became exceedingly problematic. The large number of patients admitted with COVID-19 necessitated a decrease in the staff versus patient ratio. To allow doctors and nurses to completely focus on their patients, a reduction in the overall workload was required.

Solution and implementation of a command centre

To increase the ease of communication and lower the workload, an ICU command centre was set up. The command centre is a room located about 30 metres from the ICUs from where medical students execute a plethora of practical tasks by order of ICU staff (figure 1). A former coffee room was made available, two computer desks were created, and >20 two-way radios with accessory materials were rented from a rental company (Bink Portofoons, Leiden). Signal magnifiers were used to ensure that two-way communication was possible between the cohorts and the rest of the hospital. Next to this hardware, ten medical students were hired to run the command centre. Medical students were a logical choice of personnel since various departments in our hospital already delegated administrational or supportive work to medical students. They have sufficient medical  knowledge and are relatively cheap to employ. The students were trained and received access to our hospital’s patient data management systems. The training of new employees was carried out by ‘walking’ with more  experienced students for the first few working shifts. In addition, a file containing all the protocols and procedures was available for reference.  After a trial period, working hours were set from 8 am until 8 pm, divided into two shifts of 6 hours with two students per shift, 7 days a week.

Before doctors start their working shift, they pick up a radio and leave their pagers at the command centre. The radio can be worn underneath the PPE gown, attached to the belt or a pocket, while the microphone is efficiently clipped to the collar (figure 1). In that way, the microphone can easily be reached to send messages. To receive messages, an earpiece is connected to the radio. For the communication either one or more (up to three in the first COVID-19 wave) channels may be used, depending on the number of COVID-19 patients admitted to the ICU and the available staff. To ensure effective communication, radio etiquette is applied, which includes the use of affirmative language and general code words, such as ‘over’ and ‘out’.

The medical students at the command centre take care of cleaning and recharging the radios. Altogether, the radios lead to an effective, easy to use, hygienic and fast way of communication.