Having easy access to advice and support of clinical nurse specialists (CNSs) is a key part of the NHS England standards for adult congenital heart disease (ACHD) patients (NHS England, 2016). This is of prime importance to patients, their families and carers (Sillman et al, 2017). It is imperative to consider the effect of the COVID-19 pandemic on this aspect of the service. This article reviews the impact of the pandemic on nurse-led telephone advice service in the authors' level 1 ACHD surgical centre, especially when the nursing workforce is redeployed to other roles due to the pandemic.
Method
A questionnaire was sent to ACHD CNSs across the UK, via email, at the end of March 2020. It asked how many nurses were planned to be retained in their service and how many were planned to be redeployed. Responses were received from all 11 level 1 UK specialist ACHD surgical centres, as well as three level 2 specialist ACHD centres. The authors reviewed the calls logged by their own Trust's CNS-led advice service for the month of March 2020 and compared with those from the same period in 2019. This work was registered as an audit by the Trust clinical governance team.
Results
Questionnaire
Plans reported by the ACHD centres ranged from having no CNSs redeployed to having their entire CNS workforce redeployed, with a mean of 49% of ACHD nurses being redeployed. Centres that retained their staff tended to have already small workforces (1-2 nurses). Both centres where all their nurses were redeployed were based in London, and both reported that their ACHD consultants had taken on the patient advice service; with one being covered by a consultant who was required to work from home. Over all centres, 65% of ACHD nurse specialists had been, or were planned to be, redeployed.
As part of COVID-19 response at the authors' institution, two members of the CNS team were redeployed and two were retained. This equates to a 50% reduction in nursing support for the service.
Advice line calls
In March 2020 the CNS-led advice line at the authors' Trust logged 446 calls, compared with 160 calls logged in March 2019. This was a 179% increase. The mean monthly number of calls for 2019 was 134, so March 2020 represented an excess above the 2019 average of 312 calls, or a 233% increase.
Of the calls logged in March 2020, 308 related directly to the novel coronavirus (SARS-CoV2) responsible for COVID-19. In the first week these mostly related to issues around travel, but then the most frequent reason became about individual patients' level of risk and what precautions they should undertake. Other reasons for calls included whether to attend appointments and investigations, and wanting supporting letters for employers and others giving information on their condition and level of risk so adjustments could be made. Figure 1 shows two clear peaks on Monday 16 and Monday 23 March, both of these followed weekends when there had been major government announcements about protecting the most vulnerable (Hancock, 2020; Ministry of Housing, Communities and Local Government et al, 2020).
Figure 1. Calls logged by ACHD CNS team, March 2020
It is interesting to note there were 138 non-COVID-19 related queries during this period, which is in line with the average monthly calls from the previous year, suggesting that the high number of COVID-19-related calls were not offset by a reduction in routine telephone activity.
Discussion
These data show that there was planned redeployment of more than half of the ACHD nursing workforce in UK ACHD centres, with 65% of ACHD nurses nationally planned to be redeployed. It was not known what the impact would be from increased staff absence due to self-isolation with COVID-19, but clearly a reduced workforce will become less resilient to absences. There is a significant need for nursing support as part of the COVID-19 response, especially the skilled nursing involved in intensive care/critical care, but it is important to consider the impact on services for patients with long-term conditions who are highly vulnerable. The experience of two out of three London specialist centres having their entire CNS workforce redeployed may indicate that other centres will have lost more of their CNSs than planned, given that London was severely affected earlier than other regions.
This comes when the demand for telephone advice has significantly increased, with the authors' centre receiving a 179% increase in calls compared with the same period in the previous year. This does not take into account the volume of patients seeking advice through email. It can be seen that calls significantly increased following major announcements on advice for vulnerable patients. It can then be expected that any further announcements would elicit similar increases in demand, which a depleted nursing workforce may struggle to deal with. Although clearly ACHD consultants will have the knowledge and skills to deal with clinical advice, they may not have the experience to deal with the whole range of issues that ACHD patients seek advice on.
Level 1 ACHD surgical centres are required to have at least five specialist nurses, by standards set by NHS England (2016). This requirement relates to total numbers rather than those present on any 1 day and is based on having a resilient service. As the COVID-19 pandemic led to a reduction in elective clinical procedures and face-to-face reviews at the same time, it may well be that services were able to cope with the increased telephone demand. Patients were clearly seeking advice from professionals who they not only knew had expert knowledge on their specific condition, but were also familiar with and had great trust in. It is important that even when demands on health services are at their greatest, these patients' needs be met.
COVID-19 has been an eye opener for planning in terms of any possible epidemics and pandemics in future. This study highlights the importance of specialist nursing support for ACHD patients in times of greater need such as the current pandemic.
Conclusion
The authors recommend that ACHD centres should review redeployment plans to ensure the essential required number of CNS are retained in their service to assist patient safety in the community and provide timely expert advice. Centres should also have plans in place to mitigate reductions in the workforce, and factor in likely further peaks in demand; such as when any changes to public health measures are announced. Planning ahead for any such public health issues in the future is of prime importance.
KEY POINTS
- Patients with a long-term condition rely on advice from clinical nurse specialist
- Advice specific to their individual condition is important, especially for patients whose conditions are less common
- Demand for advice increased significantly due to the COVID-19 pandemic
- While pressures on health services from a pandemic means specialist nursing staff are called upon to help in different ways, maintaining adequate numbers of staff to support existing patients is vital
CPD reflective questions
- How do patients and families get specific advice about their care in your service?
- What is the impact on patients and families if these services are disrupted?
- How do you balance the demands of caring for patients affected with a pandemic, with maintaining services to patients, especially those vulnerable to the pandemic?