An evaluation of the experiences of an ECMO clinical support team implemented during the COVID-19 pandemic

Introduction

The first confirmed case of coronavirus in the United Kingdom (U.K.) was reported at the end of January 2020, a day after the World Health Organisation (WHO) declared the novel coronavirus outbreak as a ‘public health emergency of international concern’. By the end of February 2020 COVID-19 had spread across six continents, leading to the outbreak being declared a pandemic in March 2020 (WHO 2020). By September 2020, in the U.K. there had been 341,628 reported cases of COVID-19 infection (date of specimen) (PHE 2020a) and 41,544 deaths (within 28 days of positive test) (PHE 2020b). Approximately 4% of people with COVID-19 required an intensive care unit (ICU) admission for respiratory support (Wu & McGoogan 2020), with most patients requiring mechanical ventilation within the first 24 hours of critical care (Mahase 2020).

The rapidly evolving pandemic has led to unprecedented disruption to health services across the world. In response to a steady rise in cases occurring in the U.K. since January 2020, nationwide and local measures were introduced in the National Health Service (NHS) hospitals to meet this emergent challenge. Elective procedures were cancelled or deferred, higher quantities of ventilators and personal protective equipment were sourced, new hospitals were built, and NHS staff were redeployed and trained to new roles to meet the increased demands for critical care provision (Stevens 2020; Vera San Juan 2021).

Furthermore, the COVID-19 pandemic has posed multiple challenges for healthcare workers internationally. When working during a pandemic, these staff face elevated risks of infection, disruption of their work routines and of their professional development (Stevens 2020), as well as concerns about their mental well-being (Spoorthy 2020).

It was approximated that 5% of patients with COVID-19 may have more severe disease complications, including respiratory failure and acute respiratory distress syndrome (ARDS) (WHO 2020). As extracorporeal membrane oxygenation (ECMO) has previously resulted in a reduced mortality in Middle East respiratory syndrome (MERS) (Alhazzani et al. 2020) and Venous-Venous ECMO (VV-ECMO) enables total lung rest, it was considered that VV-ECMO may also be helpful in treating patients with an ARDS-like response to COVID-19 with refractory hypoxemia for whom mechanical ventilation was insufficient (WHO 2020). In April 2020, 898 patients were referred to ECMO services nationally, an increase of 995% from April 2019, 18% of whom were accepted and admitted to an ECMO centre (Warren 2020). As one of only five NHS commissioned ECMO centres in England, Manchester University NHS Foundation Trust contributed to an increase in ECMO provision by increasing capacity on its cardiothoracic critical care unit (CTCCU).

ECMO is resource-intensive and requires specialist trained staff to manage patients receiving it (Yang 2020), therefore the cardiothoracic critical care management team requested staff to volunteer to form a support team that would carry out basic nursing care and provide additional support for the moving and handling of adult patients on ECMO, thus releasing the nursing team to perform more highly skilled tasks. Amongst the volunteers were a mixture of clinical and non-clinical staff, including physiotherapists (Kimberley Driver, Danielle Shaffi) and physiotherapy assistants, who had been redeployed from their usual roles.

The purpose of this study is to evaluate the implementation of a novel ECMO clinical support team (ECST) that aided nurses caring for adult patients with COVID-19 and requiring ECMO. In order to do so, this study presents the views and opinions of the staff comprising the ECST.

Methodology

Study design and sample

Two questionnaires were distributed in printed and electronic format to be completed anonymously by staff during the last two weeks of the ECST’s deployment. One questionnaire aimed to gather information regarding the CTCCU nursing staff’s experiences of being supported by the ECST; these data are presented elsewhere (Shaffi et al., manuscript submitted for publication). The second questionnaire (Appendix 1) invited all staff members of the ECST to anonymously share their views and experiences of their redeployment. Seven completed surveys were returned, a response rate of 44%.

Ethical approval

This service evaluation was discussed with the research office in the Trust and was deemed to not require ethical approval. It was approved and supported by the cardiothoracic critical care senior management team. All participants consented to their responses being shared anonymously.

Data Analysis

In order to analyse data qualitatively whilst also providing a descriptive account of the frequency of different categories and themes (Gbrich 2007), survey responses were analysed using inductive content analysis (Elo & Kyngas 2008). This type of analysis is appropriate for studies when there is scarce or no prior research regarding the study topic, as it provides a systematic and objective means of describing and quantifying phenomena (Schreier 2012). In order to derive findings by means of focused evaluation questions, narrative data is categorised into coded categories and themes derived directly from the text rather than from specific hypotheses or theoretical frameworks (Thomas 2006).

Two authors (Kimberley Driver and Emma Shaw Núñez) read all data repeatedly to attain an overarching understanding of the dataset, and the data were transcribed to facilitate subsequent steps of analysis. Both authors inductively coded these data by initially labelling condensed meaning units, then formulating codes and grouping codes into categories (Erlingsson 2017). Categories were derived both from counts of codes within the data and based on how they related to a specific issue or idea. All authors reviewed the emergent categories, and the third researcher (Danielle Shaffi) was involved for the remainder of the analysis process for triangulation purposes. The emergent categories were grouped and organised into meaningful themes (Table 1).

Table 1: A breakdown of themes and categories.

Themes	CST staff expectations	Training for the role	Experience of the role	Change and development
Categories	Role and responsibility	Positive training experience	Team organisation	New skills
	CTCCU staff prior knowledge of the role	Understanding the role	Feeling supported	Appreciation of CTCCU staff
		Feeling prepared	Team working	New perception of self
			CTCCU staff knowledge of the role	Role development
			The reality of the role
			Positive experience
			Valued/contributing

Results

Of the seven questionnaires returned, five were completed by staff members who were part of the ECST during the period of increased pressure on CTCCU staff (9 weeks). Two respondents had ended their redeployment early at 1 week and at 6 weeks after returning to their original workplace due to not feeling needed in the ECST and due to an aggravated back injury, respectively. Of the seven respondents, five staff members had no prior experience of working in critical care and were mainly outpatient-based, one had extensive past experience and one had some past experience of working in critical care in a therapy role.

Four main themes were identified from staff’s feedback:

1 ECMO clinical support team staff expectations.

2 Training for the role.

3 Experience of the role.

4 Change and development.

Derived from these findings, salient good practices and recommendations to improve future implementations of support teams in an ICU setting are discussed.

ECMO clinical support team staff expectations

Staff provided accounts of their understanding of the role of the ECST, as well as their individual responsibilities, at the time of joining this newly formed team. Prior to their training, staff had broad and generic expectations about what their role would entail and the tasks they would be conducting as a team, which were based on the limited information they had received.

‘The role was described first as the “proning team” but after the training day I soon realised we would be helping with personal care’. (P5).

They expected to be involved in patient handling, particularly oriented towards proning patients, and to assist nurses.

‘I went into the training with very little expectations as we hadn’t received much information before attending the training. I knew we would be involved with patient handling and that all patients would be Covid+ but apart from that I kept an open mind about what we would be expected to do’. (P4).

Additionally, several staff members who participated in the ECST highlighted that some of the CTCCU colleagues they joined appeared to not be aware of the role of the team, prompting suggestions to communicate this in advance to all staff involved if a future ECST was to be implemented in the future.

Training for the role

All staff provided positive feedback about the face-to-face one day training they received from practice education facilitators with ICU nursing backgrounds, which for most participants was their first experience in auxiliary care within an ICU environment. They found the training was an overall positive experience which enabled them to understand their role better and feel prepared for it.

‘I felt confident the day I started on CTCCU to jump in and offer help where needed.’ (P4).

‘The trainers were friendly and made me feel at ease and reassured.’ (P7).

Prior to attending the training, staff were unsure about the tasks they would be required to contribute to. Four staff members expressed that attending the training increased their preparedness for the ECST role they were about to commence and made them feel more competent and comfortable.

‘I was unsure what additional tasks we would be asked to do prior to the training however felt more competent to complete these after training’. (P2).

Three respondents also identified areas of training that they would have found beneficial to expand on, including more training about the CTCCU environment and additional hands-on training. Overall, the training was well received, and staff reflected on it being informative and well delivered, helping them to understand better their role by clarifying their expectations.

‘There were a couple of tasks I didn’t expect to be doing but after the training felt a bit more comfortable with the role’. (P5).

Experience of the role

Participants largely found the experience a positive one, both valuing the opportunity to support a team under considerable pressure and uncertainty, as well as feeling valued for their contribution to patient care during a challenging period. This was reinforced by the positive feedback that the CTCCU nursing team gave them.

‘It was a challenging yet positive experience because I felt like I could offer help and assistance under difficult circumstances to take some of the pressure off the nursing team’. (P7).

‘The nurses have provided very positive feedback and are always grateful for support therefore I feel it has been successful’. (P2).

When reflecting on their experience of their role within the ECST, participants highlighted the level of support they received from critical care staff, senior staff and colleagues:

‘The support from everyone on CTCCU has been amazing, everyone… cleaners, nurses, students, doctors, management, porters’. (P7).

However, two team members indicated that it was challenging to work without direct supervision from a senior member of staff.

‘It wasn’t always clear who we should speak to if a problem arose, especially if it was on a day [ECMO clinical support team leader] wasn’t working’. (P4).

When asked about areas for improvement, three members felt an earlier implementation may have improved the impact of the ECST.

‘I feel team was implemented too late and was told by various people 2–3 weeks prior to team starting was when they needed us’. (P1).

As part of their feedback, members of the team provided suggestions that would have made their role more efficient:

‘We also occasionally would receive mixed messages about where we should work which would mean that too many or too little of us would end up in Covid+ areas’. (P4)

‘… … was often stood for long periods not doing anything’. (P1).

Communication was also highlighted as an area for attention, with six of the seven team members commenting on the critical care staff having a lack of awareness of the ECST’s presence or role.

‘The nurses at the beginning were not sure of our role or expecting us to be working with them’. (P3).

Some team members felt that ensuring the nurses were fully informed would have empowered them to use the ECST more effectively.

‘… therefore took time to build up rapport and trust and confidence to complete additional tasks.’ (P2).

Most (5/7) of the ECST commented on the positive way in which the members of the team bonded and worked well together in a short time. They also described the nursing team as accommodating and helpful, which enabled effective cross-team working.

‘All members of the team worked well together and it never felt like there was any friction even though we had all come from different professions, bands and experience levels’. (P4).

‘To witness first-hand the professionalism, dedication and care from everyone on CTCCU towards the patients just fills me with awe and gratitude for everything they do and represent’. (P6).

Change and development

ECST members reported they developed new skills from the role they occupied during their time on CTCCU. Largely, the group did not provide specific examples, however one individual cited infection prevention as something they would take back to their workplace.

ECST members’ accounts depicted a newly gained perception of their skills and abilities. Most (5/7) team members described realising their resilience and growing in confidence as a result of their experiences.

‘I have become more confident and feel I am a team player’. (P5).

‘This experience has taught me I am more resilient than I previously believed’. (P4).

Five respondents described how their role developed over time. This was as a result of support team members becoming more familiar with critical care staff, more confident and adapting to the role.

One member commented the role could develop with additional jobs being assigned to the ECST:

‘Once on CTCCU we realised there were more jobs for us to do, stocking, emptying bins and catheters and as we got more confident helping out a bit more’. (P5).

The role undertaken by respondents also grew as the nursing team’s confidence in the ECST developed, resulting in the nurses utilising the ECST more frequently and effectively.

‘We found the longer we were there the more involved we got’. (P3).

‘I could sense the confidence from the nursing staff in our ability to undertake tasks grow as the shifts progressed’. (P6).

Team members indicated their admiration for the CTCCU staff and made reference to their work ethic, dedication and care. Some ECST members had previous experience of critical care, either professionally or personally. Working as part of the critical care team in this role deepened their appreciation of the care provided. Other members of the ECST had no experience of critical care and expressed similar appreciation for the care provided to patients in CTCCU.

‘They have shown true courage and skill during pandemic’. (P2).

‘All the staff are so committed 100% to their jobs’. (P5).

‘The team are all fantastic and dedicated and work so hard’. (P7).

Discussion

This work presents a service evaluation of an ECMO clinical support team in a busy ICU during the COVID-19 pandemic. Additionally, it identifies a set of good practice points and recommendations stemming from staff feedback, aiming to further improve the implementation of such staff workforce if required in the future.

Firstly, despite the team having limited knowledge initially about what the role they were volunteering for would entail, the training provided served to clarify this, with ECST members reporting it adequately prepared them for the task. Secondly, to maximise the scope and usefulness of the training, staff have suggested it could be expanded to incorporate further hands-on skills and further opportunities to experience the critical care environment. Thirdly, staff felt supported whilst working as part of the team, particularly by senior staff and colleagues, but may have benefited from direct supervision and direction. Fourthly, staff indicated that strategies such as a predetermined list of tasks that ECST staff would be responsible for undertaking, clear direction regarding which areas of the critical care unit required assistance, a rota to match the number of staff on shift to the required level of support at the time, and more extensive communication to nursing colleagues about the implementation and the role of the team could be measures that would improve the efficiency and value of the ECST.

In short, staff feedback suggests that a timely implementation with appropriate training and a designated list of tasks with direct supervision would enable a similar critical care support group to be redeployed more efficiently. Informing CTCCU staff of the presence and role of the ECST would enable the team to be utilised more effectively and to increase the team’s capabilities over time.

It is noteworthy that members of the ECST felt valued and useful during a time of uncertainty and of great, rapid changes to the healthcare systems and provision, including staff redeployment. Contributing to the ECST made staff feel part of something special and was perceived as a positive experience. The team worked well as a unit, despite their multiple backgrounds, skills and experience and, following their first-hand experience, they expressed an appreciation for the work and dedication that characterised the CTCCU staff they worked alongside. Furthermore, their responses highlight that staff gained and developed new skills, confidence and perspective through their role.

These findings are important in the context of healthcare systems worldwide preparing for probable future viral outbreaks that will necessitate temporary but timely changes to care provision. Staff views and suggestions elicited by this evaluation could be utilised to understand and thereby improve the experience of healthcare staff redeployment into an ECST in the future. Thus, these findings can aid planning workforce restructuring during future viral outbreaks or other similar crises and contribute to safeguarding the well-being of healthcare staff at a time when both staff and whole healthcare systems are navigating new and rapidly changing pressures.

A number of limitations of this evaluation have been considered. Firstly, this evaluation required an inductive content analysis approach, which can present issues of validity and trustworthiness. Through the conduct of this evaluation attention was paid to its catalytic validity, as evidenced by the potential implications of the findings for clinical practice and for further research (Kincheloe & McLaren 2000). Additionally, a focus on dependability, confirmability, credibility and transferability (Guba 1981; Shenton 2004) was maintained by means of an open account of the methodology and process of analysis, a collaborative interpretation of the data between researchers, the use of triangulation, and consideration of relevant characteristics about the participants and the wider context in which the findings are situated.

Secondly, the use of questionnaires for this study was preferred to other methods of data collection due to social distancing measures in the workplace and time efficiency. However, it is recognised that gathering data by means of focus groups or interviews would have enabled more in-depth accounts and richer data.

Finally, possible selection biases may influence the findings. Staff were voluntarily redeployed from their usual roles to the ECST and self-selected to contribute to this evaluation, therefore respondents in this study might have different views to those who did not opt to participate. Two authors (Kimberley Driver, Danielle Shaffi) were members of the ECST, which could be argued may limit their ability to be objective. However, this could also enable these authors to have a deeper understanding of the context described by respondents. The evaluation also did not provide an in-depth examination for the reasons why some staff members did not join the ECST nor why some ended their redeployment early.

This timely and novel evaluation adds to a growing body of data on the innovative redeployment and training strategies implemented by health systems worldwide, often under unprecedented time and staffing pressures, to provide care to patients with COVID-19 and high care needs (Vera San Juan 2021). Future studies are needed to understand the experiences of staff adapting their work roles following the COVID-19 pandemic, to explore the impact on the well-being of existing and redeployed staff, and to evaluate the effectiveness of workforce restructuring measures taken to support the provision of care for COVID-19 patients in critical care settings.

Key points

1 Redeployed staff can successfully provide meaningful support in a critical care unit without extensive training or prior experience of the environment.

2 This is not at the detriment to the well-being of these staff, who can have a positive experience and gain valuable transferable skills.

3 A defined support structure and comprehensive communication are essential to ensure both existing and new staff have a good understanding of the newly formed team’s role.

Acknowledgements

The authors would like to thank all the staff working in CTCCU at Wythenshawe Hospital, and are particularly grateful to the members of the ECST who provided their views during this evaluation. The authors are also thankful to the senior management team of CTCCU for supporting this evaluation and to Dr. Julian Barker for reading a manuscript and providing feedback.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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