‘Permanent winter’: a day in the life of a hospital dealing with flu and strikes | NHS

TThirteen ambulances are lined up at the rear of the emergency department (ED) at Royal Stoke University Hospital, Staffordshire, as Ann-Marie Morris, the hospital’s deputy medical director, walks towards the entrance, squinting in the weak afternoon sun. Behind the closed door of each vehicle is a sick patient, some of whom have been waiting for four hours or more, backed up in the parking lot, just to get through the door.

The reason they’re stuck here is because there are no beds in the emergency room – and there’s not much space in the hallways either. In the cramped lobby, a group of paramedics and a senior nurse in hi-vis are huddled around a computer station. Behind them, a corridor extends toward the ward, where at least six or seven beds are lined head to toe on one side, each occupied by a patient. To the left are three more beds and three more tense and vigilant patients. Another patient and another bed are on the right.

“So…it’s busy,” Morris said. “It’s not our worst day, but just as…it’s a challenge to deal with, I would say, today.”

It was a day marked by huge logistical problems and considerable personal stress for those working in this large regional NHS centre. The Royal Stoke is absolutely full, with every usable bed out of a total of 1,178 occupied, and few more (in addition to the 15 patients being treated in the emergency corridors, a further 20 are in the same position on other wards). The hospital’s Operational Pressure Escalation Level (OPEL) risk level stands at 4, the highest possible designation before it must declare a critical incident – ​​meaning it cannot necessarily provide all of its services safely.

In other words, it’s just another winter Tuesday in the NHS. Britain’s National Health Service is under exceptional pressure this week, with an unprecedented early rise in flu cases reaching the highest number of cases recorded for this week in December, colliding with a five-day strike by resident doctors which began on Wednesday. This has led to apocalyptic talk from some health officials about this year’s “worst” winter crisis, warning of a “flu-nami” that one A&E consultant described as a potential “Armageddon”.

But for the battle-hardened Royal Stoke staff, these are just two more complications – important and annoying as they are – in what is already an exhausting ‘permacrise’. Yes, winter brings enormous challenges, but “it would be fair to say that I don’t think we’re ever out of winter,” says Dan Hobby, chief nursing officer of general surgery. “It almost feels like winter lasts 12 months a year. We’re in winter all the time.”

The Guardian was invited by the North Midlands University Hospitals Trust to spend a day at the Royal Stoke, speaking to staff about how they care for patients while battling the sometimes more complex task of managing their progress in a blocked system – one bed at a time – to free up space for others.

Hospital ward staff speak candidly about the timetable challenge of trying to meet enormous demand with permanently limited beds. Patients praise the care they receive from resourceful, dedicated and tired medical professionals.

However, the hospital does not want to share everything. We are stopped at the emergency room door and away from the crowded area where people are being treated in the hallway. Photographs are out of the question. Corridor care has long been standard practice in many hospitals, but the brutal reality of the NHS bed crisis can seem too painful to expose to others.

In a garlanded respiratory room on the upper floor, Dr. Ashwin Rajhan meets Raymond Dutton, a 74-year-old former police officer suffering from motor neurone disease. Dutton has a tracheostomy tube that allows him to breathe but interferes with his speech, so he happily communicates with smiles, gestures and writing on a smartphone, while the machine keeping him alive whistles in the background.

Rajhan, one of 18 respiratory consultants, says the flu outbreak poses a particular risk to vulnerable patients such as Dutton, and has set up side rooms where patients can be isolated at a particularly high cost throughout the hospital. “We see a large number of flu patients but fortunately few of them need to be admitted to intensive care,” says Rajhan. The resurgence of the disease has undoubtedly been a problem in the region – on December 6 the hospital along with five other hospitals in the West Midlands declared a critical incident regarding the number of admissions – but in the last fortnight “we seem to have stagnated”.

The big question is whether an early surge will mean this winter’s flu goes away sooner or, as many at the hospital suspect, lead to a second surge after families gather for Christmas. Either way, when the room is full but beds are needed, some ingenuity is required.

“Today was a good example,” says Rajhan. “When we arrived in the morning, we were told that there were four patients in the emergency room who had to come to this department because they needed NIV. [non-invasive ventilation].” The 28-bed room has a capacity of 20 NIV beds; there were already 21 of them. “So we had to pass all the patients individually, get the physiotherapists on board and ask them to see the patients urgently” to bring them to a departure location.

The department’s computers were not working, slowing the discharge process. “One of the dump facilitators physically went to another part of the building, dragged the IT guy, and as we speak, he’s in the process of replacing all the computers.” Each bed vacated by the consultant meant another person could be moved from the emergency department, thereby emptying another ambulance and allowing another very ill person to be picked up by paramedics and taken to hospital for the process to start again.

Such bursts of individual initiative come with a series of levers that clinicians can pull to release steam from the overheating system. “Admission avoidance techniques” include “hot clinics,” where patients are considered outpatients, and Cris, a community response team that visits patients’ homes to preempt emergency admissions. At the hospital, a process called “In-Reach” allows specialist staff from one department to consult patients who have become stuck in another department because there is no room for them. After their discharge, the “virtual service” allows patients to go home to follow their hospital care.

But institutional impasse remains one of the hospital’s biggest challenges. In the intensive care unit, a major trauma unit whose patients include those who have undergone cardiothoracic surgery, Tracey Wootton waits to be transferred to a general medicine ward. The national standard for traveling with patients like this is four hours; Wootton has been here since Saturday, three days ago.

The observation is similar within the surgical evaluation unit, which covers specialties ranging from ENT to gynecology. Since being forced to hand over their service to another service in October, patients are now waiting three days for a transfer instead of 24 hours. The SAU is a “chaired” unit, meaning patients are assigned lounge chairs. Its capacity is 30 people; it currently has 55 patients. “Unfortunately, patients also end up in plastic chairs, which is not ideal,” says senior nurse Molly Merrison.

Senior staff were optimistic about the resident doctors’ strike, the 14th such strike in their long-running dispute; others, however, say the impact will be “massive.” “I think from a discharge point of view, because everything is now on computer systems… how shall I put it… if you don’t have your regular staff, they may not know exactly what needs to be done,” says a senior nurse. In other words, consultants don’t know how computers work to discharge patients.

“It’s a learning curve, I can’t deny that,” smiles Rajhan, a pulmonology consultant, “but equally, I find it easier to pick up the phone and speak to another consultant colleague in another department. Yes, I may take more time than getting into the computer system to type, but the decision to get there is much quicker.”

While clinical procedures and treatment decisions took place throughout the day, in a windowless room in the heart of the hospital, clinical operations manager Becky Ferneyhough and her colleagues on the site operations team sat under large computer screens (and string lights), monitoring a series of graphs measuring movement capacity and patient flow in each ward and department of the hospital, to enable decisions to be made about moving resources where needed.

Four times a day she meets with senior colleagues from across the trust; during Tuesday’s meeting at 8:30 a.m., 12 ambulances were waiting in front of the emergency room, including one for 6 hours; by lunchtime it was eight o’clock. We check in again after 5 p.m. “We have 20 ambulances outside,” says Ferneyhough. “We had a very difficult afternoon.”

It must be stressful to have these conversations about numbers and resources, when we’re talking about real people. “Absolutely, 100%,” she said. “The patient is the most important part of everything we do and it’s really difficult to find a balance between doing what’s right for the patient – ​​but also for all of our patients.

“It’s not just about the patients we have in the hospital, it’s also the patients who will be our next patients, who are at home waiting to come into the hospital. Some of these decisions are really, really difficult to make.”