Abstract
The COVID-19 pandemic continues to be an enormous challenge to healthcare systems worldwide. 1 At a time when healthcare resources are already severely constrained, intensive care services around the world have had to adapt to this challenging, novel contagious disease, 2 including by creating new hospital facilities. 3 In the UK at the time of writing, there have been >260,000 cases and >11,000 critical care admissions, with approximately half requiring ventilation. 4 In London, outbreak modelling predictions anticipated a peak demand for critical care exceeding existing capacity by >3000 beds, requiring rapid rationalisation and adaptation. 5 NHS Nightingale London was created at pace in a large conference centre as an emergency surge hospital to manage ventilated patients.
Logistics, hospital anatomy and communication
A combined military and civilian taskforce equipped the hospital in six days, with the first patient arriving on day 9. A workforce model was created with volunteer clinicians recruited from NHS trusts, returners to practice and locum agencies, and retrained non-clinical staff.
The clinical area (Figure 1) comprised ‘dirty’ wards at the periphery of the building, with personal protective equipment (PPE) – donning and doffing clean areas – along a central corridor. The operations zone and medical leadership were sited in the central ‘clean’ area. Communications between these areas, required for clinical, operational and logistical tasks, posed significant challenges due to their disparate locations and constrained movement between dirty and clean zones. Telephone and radio contact was also impaired in the dirty zone by the difficulty in moving these devices to the ear. Hands-free systems could not be commissioned in the time available.
NHS Nightingale floor plan.
Within the Nightingale-style wards themselves, communication was further compromised by PPE, 6 which made recognition of individuals and the nuances of non-verbal communication challenging. 7 Constant background noise within the open-plan conference hall further degraded information exchange. Nationwide shortages of PPE limited staff movement and information between dirty and clean areas. A constantly changing workforce and clinical model exacerbated the need for better information distribution.
Workforce
A shortage of critical care nurses and doctors required novel ways to enhance their productivity and they were augmented by clinicians, registered nurses and allied health professionals working in unfamiliar clinical roles with custom retraining. Every shift brought a different mix of staff and skills, some new to the hospital. These challenges were common to many London Trusts during March and April 2020, but at NHS Nightingale, the attendant difficulties were compounded by the lack of a pre-existing staff, corporate infrastructure and identity. Managing human factors in relation to a clinical team unfamiliar with each other, working in an unusual environment for long shifts in full PPE, became more acute at NHS Nightingale than in a conventional hospital setting and it became clear that a different way of facilitating communication, logistics and clinical practice was required.
The tactical commander
A tactical commander role was created to maintain an overall situational awareness, to enhance communication ‘down and in’ (leadership to clinical team) and ‘up and out’ (clinical team to leadership), and to close the loop on the improvement cycle. The role was initiated at pace, after the first few days of opening to patients, when it was recognised that communication difficulties due to the geography of the hospital, lack of corporate knowledge and staffing inconsistencies may compromise patient safety and staff wellbeing. The tactical commander model has previously been utilised in deployed military medical operations to enable clinicians to focus on care delivery.8 The tactical commander liaised closely with the critical care consultant and matron inside the clinical area, and operations staff and medical leadership outside the clinical area. They also had close liaisons with embedded Bedside Learning Coordinators, who identified key areas on a daily basis for improvements on the clinical floor. Individuals selected for this role were senior middle-grade clinicians with experience of clinical leadership in austere environments. Delegation of these command, control, coordination and communication (C4) functions was invaluable to the clinical teams, enabling a low clinician-to-patient ratio (1:42 intensive care unit consultants and 1:4 intensive care unit nurses), without compromise to patient outcomes. This tactical commander role had important contributions to risk management and reduction via a risk register and quality and improvement, due to the improved C4 enabling audit and improvement activity to occur at pace. Staffing management was also improved significantly following the tactical commander introduction, with an extraordinarily low absence rate of 1.6%, compared with up to 20% nationally 9 due to the introduction of staff check-in procedures and robust welfare and occupational health support for all staff.
As opposed to purely a leadership role, the tactical commander was deemed a supporting force to the leadership, and clinical team at the coalface in equal measures. This ‘flattened hierarchy’ at NHS Nightingale has been celebrated as a concept that encourages instigation of change, patient safety and staff wellbeing, empowering all to have an equal responsibility to make a difference, and improve ways of working. 10
Conclusion
Effective C4 is required within any hospital but is particularly important when working in austere and resource-limited environments. Workforce unfamiliarity, physical restriction of communication and a rationed staffing model highlighted C4 as a key function in such unconventional circumstances. The tactical commander model can be implemented in any non-conventional clinical area, where the benefit of enhanced oversight and streamlined communications can have a tangible impact on patient safety.
