Ward rounds have been a part of my weekly schedule for almost five years. I am an advanced nurse practitioner working in a forward-thinking CCG, which has been providing ward rounds to residents in residential and nursing homes as part of standardised care across the borough. But since the Covid-19 pandemic, we have had to adapt.
I provide a weekly ward round to 36 residents in a residential home and discuss any challenging patients with a GP. This is revolutionary in comparison to how medical care used to be provided to them – on an ad-hoc, as-needed basis, always by a GP, and usually for acute medical needs. It took me some time to feel comfortable in assessing diagnosing and implementing care in the community, which somehow felt different to doing exactly the same thing in surgery.
But I soon found that ward round day was my favourite of the week. Taking care of the senior members of society, all with a story behind their eyes. Sometimes they tell me their story but often I gleam it from photos in their rooms; weddings, often loved ones in military uniforms, groups of family photos. It takes time to build up professional relationships with the staff and the confidence in their assessment of what needs an urgent visit for a poorly or declining resident.
Everything changed with Covid-19
The arrival of Covid-19 completely changed how I was able to safely deliver my ward round. I had previously used FaceTime to keep in touch with family and friends, but had never assessed a patient by video link. This sent me into a spin. How was I going to assess without undertaking a physical examination? How could I assess an individual’s condition without touching or feeling? Previously, all my diagnoses had been based purely on a hands-on assessment: temperature, pulse, feel of the skin, blood pressure and examination of systems as indicated by the presenting complaint.
Most of my residents are affected by dementia and the history of their complaint is provided by a carer. But as carrying out a physical assessment to exclude or confirm a possible diagnosis was impossible, I had to draw on new skills to ask key questions. The senior carers were trained by our fantastic district nursing team – who visit daily – to take temperature and oxygen saturation to assess in identifying early possible Covid-19 cases, which was reassuring. But we had to get used to poor internet connection, transmission delay and residents not realising that it was me on the other end of the phone and their poor cooperation, which is usually easier to overcome in person. For those that needed physical assessment, the CCG provided a visiting team to support GPs where needed.
Meanwhile, there has been enormous stress on care home staff caring for residents in their own rooms to prevent spread of the illness. Staff sickness has increased their workload and it is all made harder by having to wear PPE. Through regular telephone contact throughout the week, our practice has tried to show that we care for the wellbeing of the staff. Through this remote access, the care home managers feel they get immediate advice, rather than having to wait for either me or a GP to be able to visit.
Looking to the future
Though it took longer to undertake the ward round initially, we have now adjusted. I am excited for the future. We have proved that we can provide appropriate care remotely and aim to continue this. Being launched into a world of remote assessment has enabled me to embrace this change and envisage a future that includes the continuation of remote working.
That said, nothing can replace the hands-on approach to hold someone’s hand or wipe away their tears, or try to reassure someone who is frightened as they don’t recognise where they are due to dementia. I will look forward to my scheduled visits to the home although these, unless required, will most likely not be weekly. Covid-19 has shown us how we can work cohesively and effectively with residential care staff and district nurses. Most importantly, that change can be embraced and successfully implemented in a very short space of time.
