THE COVID-19 pandemic continues to create an unprecedented upheaval in the delivery of health care across the world, including parts of Australia. This article documents the experience of an outer metropolitan hospital, Nepean Hospital at Penrith in New South Wales, and the changes that occurred as a result of the pandemic. It also aims to describe a new normal as the pandemic continues to ebb and flow and forces clinical practice to proceed with its sword of Damocles influencing each decision and approach.
Nepean Hospital is a 600-bed tertiary referral hospital on the outskirts of Sydney and is part of the Nepean Blue Mountains Local Hospital District (LHD). The hospital is organised into Divisions (surgery and anaesthetics, medicine, cancer services, critical care and emergency department, and women’s and children’s health). Each division has Clinical Directors and nursing and business units that report to the General Manager. In turn, there is reporting up to the LHD through a Director of Operations and on to a Chief Executive Officer.
By February 2020, it was clear from international reports that the pandemic was affecting Australia, with rising numbers of positive cases (albeit small) and local and statewide modelling suggesting that the hospital would be overrun by April.
A number of immediate steps were taken, including the establishment of a districtwide incident management team (IMT) and a local hospital IMT. Wards were closed and redesignated to assist in triage and direction of patients. A local hospital triage team was established headed by the executive medical director and senior clinicians. Decisions were taken about elective surgery, which was moved to a co-located private hospital through a contract designed under a collaborative care umbrella. Telehealth, videoconferencing and remote consultations became the norm. These major changes occurred within a matter of days to a couple of weeks.
A hallmark of the rapid decision making was the establishment of a daily 8 am meeting, chaired by the General Manager, which included all senior clinicians and management of the hospital, and featured status reports and plans for the day’s activities. A second meeting at 3 pm each day reviewed the activities and invited a wider audience so that all incidents, difficulties and barriers were cleared into one central informing and decision making body. Any unresolved issues were reported to the hospital or district IMT for rapid decisions and resolution.
A key challenge was the availability, use and appropriateness of personal protective equipment (PPE). This was resolved through the establishment of a group of clinicians working with the Clinical Excellence Commission to form a PPE policy that preserved equipment and simultaneously kept staff safe. Entry and exit pathways to the hospital were limited and screening was established. A COVID-19 testing clinic was rapidly created and pathways for positive and suspected patients outlined and implemented.
Clinicians from Nepean Hospital were also members of newly established, state-wide communities of practice (COP) and one clinician was a member of the COVID-19 Critical intelligence Group (CIG). These clinicians reported back to these daily meetings and formed a conduit to those meetings for evidence-based decisions to be taken.
While major clusters in the community continue to occur, it was clear, by early June, that the first wave of the epidemic was averted or, at the very least, delayed, and the hospital started to return to a new and untested normality.
The question that pervades the building is what is the good that can come out of this experience and how should the post-COVID-19 era shape the delivery of health care to encompass only those aspects which are safe, efficient and worthwhile? These are some of the positive effects which, in the view of the author, must survive into the post-COVID-19 era.
Telehealth and videoconferencing
The model that patients need not travel to the clinical environment and staff need not physically attend meetings was a major change during the COVID-19 era. Rapid increases in bandwidth allowed clinicians to contact patients through video conferencing applications (apps) and even by telephone. Patients who previously had travelled up to 100 km to the hospital to be told the result of test or a biopsy report, now could stay home and receive the news. They were able to consult their clinician and reach consensus on jointly devised clinical plans. Meetings of the hospital staff, including mortality and morbidity meetings, multidisciplinary meetings and departmental meetings, all take place via videoconferencing apps and include display of x-rays, results and pathology. This must continue.
Close cooperation between clinicians and administration
The ability to discuss issues of concern, plans and new procedures in a collegial daily huddle has been a foundation stone for rapid decision making, clarity and unity of purpose. For administration, the ability to learn first-hand from the clinicians on the coalface about the challenges facing them has led to a deeper understanding and a breakdown of the “us and them” mentality.
It is as if the viral enemy at the door galvanised a sense of united toil to overcome the barriers of bureaucratic delay. This must also continue.
Mindful and evidence-based clinical care
During the acute phase of the COVID-19 crisis, clinicians (especially surgeons) were able to triage patients into those who needed urgent care and those who could wait or be treated through different ways that reduced the impost on hospital resources. Non-surgical treatments for conditions ranging from appendicitis to prostate cancer were adopted. Low value care became non-existent. Resources were mindfully used. Multiple colleges and societies produced guidelines about various conditions and clinical models, and these were adopted to the betterment of clinical care. This must continue.
COVID-19 Critical Intelligence Group
The Critical Intelligence Group of the New South Wales Department of Health is a newly established committee of public health and clinical professionals and prepared daily evidence digests that were distributed to the clinical workforce and the communities of practice. Focused summaries of the literature on specific topics were produced on a daily basis in response to questions posed by the clinical communities. These summaries challenged the accepted norm and guided appropriate clinical care and resource utilisation. This must also continue.
During the COVID-19 era, clinicians are involved in their own waiting lists of patients, organising the hospital and participating in decision making about their clinical environment. Where once some clinicians treated the public hospital as a repository of patients who, somehow were no longer theirs, there is an advocacy for and a participation in plans to continue to provide care, despite the challenges of lost beds, cancelled theatres and diminished resources. This must continue.
Working from home
There has been a realisation during the COVID-19 era that clinicians can be productive and engaged despite not being physically present in the hospital environment. Good communication pathways through telehealth and a comfortable environment mean that research, teaching and clinical care can continue without the “clock in, clock out” mentality that imposes an artificial veil of productivity on workers. Output rather than time on the clock is recognised as the measure of good work. This must continue.
State and federal divide
Divisions were taken especially when dealing with community clusters that cut across state–federal funding divides and broke down the walls of the hospital, forming a barrier to a continuum of care stretching from the intensive care unit at the heart of the hospital to the bedside of patients affected in an aged care home in the community. Clinicians are bridging this continuum to provide medical care, testing and appropriate triage throughout the cluster of infections. Administration seems to work in a continual support loop reaching far beyond the state and into the federal health jurisdiction. The result has been rapid and effective decision making and disaster containment. This must continue.
Clinicians caring for clinicians
Throughout the crisis, a deep sense of camaraderie and care pervade the clinical community around the hospital. Those of us who were inundated in leadership duties and countless meetings found our colleagues supporting our clinical load and taking calls. We are concerned for each other and bound by a common goal to survive and to deliver the best care we can under difficult circumstances. We think of the common good instead of individual and departmental ambitions. We are a united force in the face of an advancing enemy. This must continue.
The fundamental question still remains: how do we ensure these benefits survive in an environment of maintaining the status quo and a reversion to the mean?
The answer has to be founded in structural changes to governance that allow clinicians a voice at the Department of Health table and a mutual respect between administration and clinicians founded in an acknowledgement of their respective skills. Ideally, the NSW Department of Health recognises its value is to empower, resource and serve the clinical front line in the spirit of a service management model.
Professor Mohamed Khadra, AO, is Professor of Surgery at the University of Sydney, and Clinical Director of Surgery at Nepean Hospital.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.