SARS-CoV-2, the virus responsible for the COVID-19 pandemic, has had a global impact at both micro and macro levels, and continues to do so. The pandemic has led to illness, death, and global disruption (Jackson et al, 2020), and the impact on healthcare and front-line workers remains unquantified. The 72nd World Health Assembly designated 2020 as the International Year of the Nurse and Midwife, this was to not only commemorate the 200th anniversary of the birth of Florence Nightingale, but to also recognise the imperative contribution these professions have made to the health and wellbeing of the world's population (Daly et al, 2020).
It is now apparent that healthcare staff active in caring and treating COVID-19 patients may have been some of the most vulnerable to the disease. Ford (2020) found that England and Wales had the second highest death rate of health professionals who contracted COVID-19 in the world, behind only Russia. One element that has become increasingly apparent is that individuals from black, Asian and minority ethnic (BAME) backgrounds were overly represented within the rates of those who contracted and subsequently died from COVID-19. It has been estimated that 63% of health and social care workers who died were from BAME backgrounds, which is three-fold more than the proportion of BAME workers in the NHS workforce (Kursumovic et al, 2020). Several factors were found to link individuals of BAME heritage with increased mortality, including lower socio-economic status, social deprivation, vitamin D deficiency, genetics, co-morbid medical conditions and obesity (Khunti et al, 2020).
Besides ethnic heritage, further constraints increased the risk of healthcare staff to contracting COVID-19, including a lack of personal protective equipment (PPE) and staff shortages due to shielding measures, self-isolation and sickness (Propper et al, 2020). As many have predicted, the psychological sequelae of the pandemic could persist for months and even years to come. Staff who did continue to work reported increased stress and fear of infecting family members (Spoorthy et al, 2020). Tan et al (2020) found that the primary outcomes were the prevalence of depression, stress, anxiety and post-traumatic stress disorder (PTSD). Some 72% of staff reported experiencing some mental health impact: in 55%, this was mild, but, worryingly, it was reportedly bad in 11% of staff members; of this 11%, 2% took time off work during the pandemic due to mental health issues (Moorthy and Sankar, 2020).
The case study presented here describes the experience of a nurse who contracted COVID-19 and required admission to the intensive care unit (ICU). It should be read in conjunction with McDonald and Clark (2020), published in the November 2020 issue of the British Journal of Community Nursing.
Case study
This single case study focuses on the admission and discharge of discharge of a nurse who was also a patient during the COVID-19 pandemic. To maintain confidentiality, a pseudonym has been created, and the patient will be referred to as Mr Remwell Beldia (Nursing and Midwifery Council (NMC), 2018). Remwell is a 43-year-old adult field nurse (RN adult) who moved to the UK from the Philippines 20 years ago to work within the NHS as part of an international recruitment campaign. Through his career, Remwell has progressed to become an emergency department charge nurse at a large city hospital. He lives at home with his wife, who is also a nurse, and two teenage daughters. Remwell has a history of type 2 diabetes and hypertension, which he manages well with metformin hydrochloride 500 mg TID, ramipril 10 mg OD and atorvastatin 10 mg OD. He is considered overweight with a BMI of 28 but lives a reasonably active life and is an outgoing individual, both with his family and within his community. He swims twice weekly and works as a volunteer for the Girl Guides.
During the initial COVID-19 outbreak in the UK in March 2020, Remwell and his wife continued to work in the NHS. Both daughters remained at school as their parents were key workers. In April 2020, Remwell was admitted to hospital with pneumonia, and initially the cause was unknown. He required supplemental oxygen on admission, but deteriorated the following day and required endotracheal intubation, mechanical ventilation and admission to the ICU. During his admission to the ICU, he was swabbed for COVID-19 and tested positive. Over the subsequent 29 days, he required invasive treatment and was kept in a medically induced coma throughout. Due to the criticality of his condition, he also required extracorporeal membrane oxygenation (ECMO) 5 days after admission.
Due to lockdown restrictions, Remwell's wife was unable to visit him in the ICU; she continued to work in the same hospital and care for their two daughters. Mrs Beldia reported an increase in stress, anxiety and fatigue during this time. Because Remwell was intubated, an ICU diary was kept for him as per the protocol in this specific trust's ICU. Despite incredibly busy periods in the ICU, this was completed on most days of admission. The diary discussed not only Remwell's treatment and progress, but also detailed current events (Bäckman et al, 2010). The purpose of these diaries is for the patient to be able to be able to acknowledge what happened during long periods of time lost to them whilst unconscious in ICU.
Twenty-eight days after admission to hospital, Remwell was discharged home to his family. Due to fears that he was vulnerable, both daughters were sent to live with family members elsewhere to reduce the risk of infection while they were attending school. Mrs Beldia was able to take 2 weeks off to care for her husband but, thereafter, had to return to work. Through his subsequent illness and discharge, Remwell had reported an absence of follow-up appointments from the ICU or his GP. He also reported long periods of time where he did not recall events of his life during his admission to the ICU, an experience shared by many ICU survivors.
In the subsequent month following discharge, Remwell's wife noted that he became more withdrawn and disengaged and experienced low moods. He experienced frustration at his lack of memory and found that his ICU diary was more frustrating than informative, as he himself could not recall several events. He reported loneliness, as he saw his daughters infrequently and his wife continued to work in the NHS. He also admitted feeling a sense of fear that he would ‘catch’ COVID-19 once again from his wife who was still on the front line. He also reported muscle weakness, severe fatigue, night terrors and anxiety. He described frustration at the pandemic, which not only isolated him to his home, but also significantly reduced his interaction with his family and friends, exercise and social life. Mrs Beldia felt that Remwell required input from his GP, but he was only able to secure a telephone meeting.
Conclusion
It could be argued that many patients are not receiving optimum care in the community after discharge from the ICU for COVID-19. This seems to add to the impact of this experience on the patient's mental health. Health practitioners need to consider how primary care teams can improve the care of these patients. Care plans and risk assessment/management plans need to be prepared from a bio-psycho-pharmaco-social perspective (McDonald and Clark, 2020).
KEY POINTS
- Some nursing colleagues have been hospitalised in the intensive care unit (ICU) due to COVID-19
- Routine practices in ICU are no longer followed through due to service demands (such as ICU diaries and post-discharge support), which places increasing demand on primary care services
- Post-discharge COVID-19 complications are common and involve all bio-psycho-pharmaco-social aspects of the individual
- Risk assessment and management are vital tools in the care of these patients
- Nurses may feel very frightened at the prospect of a return to work and the possibility of contracting COVID-19 for a second time
CPD REFLECTIVE QUESTIONS
- Using a bio-psycho-pharmaco-social (BPPS) approach to post COVID-19 recovery, consider the pertinent issues described by Remwell and how aspects from each domain will impact on each other. How will you address this in your care plan?
- Aspects of risk assessment and management are extremely pertinent in this case. Explore what the risks may be from a BPPS perspective? How may you reduce the risks? What will you do in the ‘worst case’ scenario?
- Consider how you can make the ICU diary become a meaningful tool to aid recovery and involve the patient's family
- Explore how you would work with Remwell to develop a plan to get him back to work