Coming full circle on rehabilitation—a community hospital during covid

William Deeley describes how staff working in a community hospital had to adapt during the pandemic, and how their learning is now being put to use in supporting the rehabilitation needs of patients who had covid-19

When the second wave of the covid-19 pandemic swept the UK, the general ward of our community hospital in Oxfordshire wasn’t spared. Our hospital is normally an enabling environment with a strong focus on rehabilitation, but at the peak of the second wave, over half of our ward was occupied by unwell patients with covid-19. This created challenges in caring for our patients and in communication, but the lessons learnt and insights gained have changed the way I practice and will continue to do so long into the future.     

Our hospital’s nursing and therapy staff who specialise in rehabilitation were suddenly faced with looking after acutely unwell patients, often requiring oxygen therapy and more observation and close monitoring. The staff adapted remarkably well and coped with the different demands and pressures placed on them, with everyone pulling together to make sure patient care was the priority. We all became more accustomed to identifying the signs of a deteriorating patient and in managing symptoms at the end of life—skills that we will be able to use in the future.

The rapid nature with which covid-19 patients can deteriorate, coupled with the inherently frail cohort of patients we see, presented a unique challenge. As a community hospital, we only have doctors on site 9-5, so creating clear escalation plans for each patient became a cornerstone of our management. We were able to give oxygen therapy, dexamethasone, fluids, and antibiotics, but our community hospital setting meant we were unable to provide level 2 care. Consequently, we had to identify early on the patients that this would be appropriate for in the event of deterioration. This involved early and often difficult conversations with patients and their families about ceilings of care and transfer status, which were made more difficult by restrictions on visiting and having to have these conversations over the phone or via video call rather than in person. 

Although the lack of visiting has been difficult for all parties, it has been the driving force for the more widespread use of video calling technology in our hospital. This was used to give families updates or to facilitate best interest meetings, and also allowed communication between patients and their family. Now that the systems for video calling are in place and staff are familiar with the technology, this can hopefully continue into the future to offer an alternative, more meaningful, and practical interaction to a phone call for our many patients who are often a long way away from their family and friends. 

Our experiences during the covid-19 pandemic made me appreciate the incredible level of trust that people place in the NHS to look after their loved ones, especially when they’re physically separated from them. Communication is so important in building and maintaining this trust, even if it is just a quick update to say not much has changed. 

In addition to the changes in how we communicate with patients’ relatives, covid-19 has changed the way I view communicating within the team. One of the toughest challenges we faced was the mental and emotional impact of seeing patients who had been with us for a long time making progress, only for them to be knocked back or not make it through. The senior ward staff and doctors encouraged us to carve out time to debrief: reflecting regularly together allowed us to process events and grow as a team. It is one of those examples of practice that I will hold onto and try to replicate with the teams I am part of in the future. 

After a long winter, we are all now feeling more hopeful. Visiting restrictions have been relaxed and teams working on the vaccination rollout have now visited a number of times to vaccinate inpatients and staff alike. We are witnessing firsthand the positive impact that the vaccine is having on severity of disease. This combined with the reduced number of covid-19 patients we are seeing has meant our community hospital has been able to return to its crucial role of helping our community’s most vulnerable and frail patients regain their confidence and independence. 

We are also seeing a new cohort of patients being referred to the community hospital. We have now started receiving patients from the acute hospital following long admissions with covid, who are much younger than the typical community hospital patient. In the aftermath of prolonged stays in intensive care, these people are deconditioned and in need of the intensive rehabilitation a community hospital can offer. We have found that this population of patients is highly motivated to get home so, as well as physical rehabilitation, there is a big focus on making home adaptations to facilitate safe and early discharge.  

Initially, our community hospital’s staff had to adapt to be able to help acutely unwell patients with covid-19—a need that took us all on a steep learning curve. It feels like a fitting conclusion that we are able to use the expertise we gained during that turbulent time to help a younger cohort, affected by the same disease, achieve rehabilitation. 

William Deeley is a foundation doctor who was trained at the University of Cambridge and is now working in the Thames Valley Deanery.

Competing interests: none declared.