The coronavirus (COVID-19) pandemic imposed unprecedented disruption to global health care service delivery. Healthcare settings had to rapidly adapt to the high demand of acute patient care and the implementation of social-distancing measures to reduce disease transmission. These challenges resulted in the prioritisation of emergency treatment over routine care across the world. In the UK, to cope with the high burden of intensive care patients observed in other countries, five emergency hospitals were opened across the country with a combined capacity to treat almost 10 000 COVID-19 cases. Ultimately, the demand for the Nightingale hospitals failed to materialise (Day, 2020), and most of their beds remained empty.
The ambulatory care settings in Bristol Royal Hospital for Children (BRHC) were significantly impacted by COVID-19 restrictions: bed capacity was considerably reduced and contingency plans were made to transform the unit into an acute adult bed ward should the need arise. This situation forced the paediatric hospital to restructure its traditional provision and to explore new initiatives to ensure the continued delivery of specialist care. Two specialties, paediatric allergy and paediatric gastroenterology, worked collaboratively with hospital management and leadership teams to facilitate the provision of specialist care to their cohorts of patients.
The Nightingale Hospital Bristol (NHB) provided an ideal opportunity for a temporary field hospital ward, to mitigate anticipated delays in diagnosis and treatment for children with both allergic and inflammatory bowel diseases (IBD). The ward was known as the Butterfly Unit. The NHB was commissioned by NHS England–South West, with responsibility for operating the hospital devolved to the neighbouring North Bristol NHS Trust; however, during standby, management responsibilities lay with the service providers.
Allergic disorders such as food allergy, asthma and allergic rhinitis are among the most common non-communicable diseases worldwide (International Study of Asthma and Allergies in Childhood, 1998; Bauchau and Durham, 2004). There was already a significant gap in the provision of allergy healthcare services pre-COVID-19, as outlined in a Royal College of Physicians (RCP) working party report Allergy: The Unmet Need (RCP, 2003). A British Society of Allergy and Clinical Immunology survey into the impact of COVID-19 on UK allergy services identified that more than 80% of day-case facilities were affected by restrictions. Only 32% of paediatric allergy services were able to undertake investigations such as food challenges or offer allergic desensitisation (Krishna, 2021).
There was also considerable demand within day-care settings for gastroenterology patients requiring initiation and regular treatment with biologic therapies. These drugs were developed following advances in the genetic and immunological understanding of IBD (Yang and Catto-Smith, 2012), and have revolutionised treatment for patients, leading to their increased implementation within UK gastroenterology services (RCP, 2016). During the COVID-19 pandemic, the advice to paediatric IBD patients was to continue with all current medication, including biologic therapy, regardless of their personal risk category or recommendation for social isolation (Kennedy et al, 2020).
Aims
This article outlines the development and delivery of a pop-up paediatric day care unit at the NHB and describes the patients' and families' experiences of this innovative care setting.
Methodology
The NHB had a capacity of more than 300 bed spaces. An application was made to NHB management for permission to develop the 12-bed Butterfly Unit area. An operational model was developed following established criteria for the provision of a ‘military field hospital’, which included approvals from the Trust and regional fire services, safeguarding team, resuscitation team, laboratories, IT, medicines management, the executive committee that had oversight for the set-up and delivery of services from the Nightingale hospital during the pandemic, and the Care Quality Commission.
Comprehensive planning is key to the success of any new service. After the decisions regarding proposed service provision were made, they were supported with defined clinic referral pathways and with clear, written eligibility criteria. The specialist nurses involved had all the relevant competences signed off and all staff had completed mandatory training. See Box 1 for guidance on setting up a new service out of an acute hospital.
Box 1.Top 10 tips for establishing a service out of an acute hospital
- Create a working group with define roles and responsibilities
- Create an agenda with regular frequent meetings
- Clear definition of the services your will offer
- Establish referral criteria
- Consider medicines management
- Develop protocols, policies, guidelines and safety operating procedures
- Think and establish protocols for emergencies
- Consider practicalities (locality, publicity, secretarial support, directions to the venue)
- Collect feedback from users
- Facilitate ongoing improvement via regular audit
A designated areas of the NHB, known as the Butterfly Unit, operated fortnightly between December 2020 and March 2021 to support the delivery of care to patients from the paediatric allergy and gastroenterology departments. Because this was a new and unfamiliar environment, it was deemed prudent to deliver low-risk investigations and procedures. Patients from both specialties (paediatric allergy and paediatric gastroenterology) were carefully selected following strict criteria to ensure both the safety of the patient and the successful completion of their testing or delivery of treatment.
The paediatric allergy team conducted food challenges, supervised feeds, antibiotic de-labelling challenges and administered sublingual immunotherapy treatment for aeroallergen allergies and biologics for chronic spontaneous urticaria. An allergy outpatient clinic was also run from this location.
The paediatric gastroenterology team used these facilities to administer biologic infusions. The inclusion criteria were patients stable on their infliximab infusions, and exclusion criteria patients initiating infliximab or those who had previous reactions to the infusion.
Patients from both specialties who required play specialist input were excluded because there was no play specialist support available on site.
A total of 107 allergy patients attended either a clinic appointment or a day-care appointment at NHB. The 26 lowest risk patients on the oral food challenge waiting-list were converted to gradual home introduction of the food at the start of the pandemic and removed from the waiting-list altogether. The remaining patients were stratified as either having a high likelihood of anaphylaxis or a low likelihood of anaphylaxis (low risk). The low risk patients were deemed appropriate for an appointment at NHB. All patients requiring sublingual immunotherapy treatment, antibiotic de-labelling, biologics injections or supervised feeds were also categorised as low risk.
At the beginning of the pandemic, 20 gastrointestinal patients had been undergoing treatment with infliximab infusions, 10 of whom fulfilled the inclusion criteria for treatment at NHB and so were invited to attend. The small number of patients deemed eligible was due to the fact that the ward operated fortnightly and the dates had to coincide with the biologic plan for the patient. Of the 10 low-risk patients invited, 9 accepted, and all received one or more infusions on the ward. One refused due to transport issues because public transport to the venue was difficult.
On completion of testing or treatment, patients and carers were invited by their named nurse to provide feedback on their experience of being cared for at NHB. Feedback was gathered using an online Google Form via an iPad issued to the family and cleaned between patients. Feedback was anonymous to ensure honest responses. In addition, the Trust Patient Experience Assurance Team visited the facilities unannounced and spent considerable time interviewing families to independently discuss their experiences.
Results
Across the two specialties, feedback was obtained from 72 of 116 parents and carers (Figure 1). The majority of those attending the unit were allergy patients; 16 (22.2%) were undergoing food challenges, 12 (16.7%) completed supervised feeds and 12 (16.7%) were listed for drug allergy investigations. Six (8.3%) children and young people were receiving infliximab infusions.
Of the 72 parents/carers, 62 (86.1%) had previously attended an appointment at BRHC with their child with 43 (69.4%) of parents of this group describing their visit as easier than their previous experience. Families particularly valued the parking facilities and felt the service was well organised. Most importantly, 54(75%) parents felt safe attending the NHB.
All parents found the NHB acceptable and 70 (97%) said that they would be happy to return; 29 (40%) said that they would prefer future appointments to be at NHB and 36 (50%) did not have a preference; 7 (9.7%) responded that they would prefer future appointments to be at BRHC. Almost all comments about the service itself were positive; most frequent comments were that the facilities felt calm and safe, were well organised and highlighted the importance of good, free parking. Negative comments focused on the signposting to NHB, the lack of catering facilities and the small number of toilets.
Some of the registered nurses relocating from the children's hospital had expressed anxieties about working from NHB during the set-up of the service, but once the service was up and running all the feedback from nurses was very positive.
Patient experience assurance team feedback
The report from the Patient Experience Assurance Team was very positive, particularly in relation to the quality of the staff, the physical environment and the parking. The team reported that patients and family members had suggested the following areas for potential improvement:
- Reviewing the written directions to ensure they correlate with the actual routes into the hospital
- Considering provision of hospital transport
- The ability to provide greater privacy, if requested, for example a privacy screen around the bed area and/or a private room for conversations with clinicians.
A further consideration might be given to providing more information to families about emergency procedures in the event of an issue that could not be managed in the hospital. There were also some admin difficulties associated with appointment letters appointment letters due to these usually being outsourced to an external company, and this was fed back to our Patient Assurance Feedback Team.
Discussion
The evaluation of a new service is multifaceted and complex. Regular audit and evaluation ensure that new services are fulfilling both their own aims and objectives, as well as meeting patient needs. As part of the process, measures of patient or carer satisfaction are irreplaceable in terms of discovering how the new service has been received by service users.
These findings are similar to the experiences of patients reported in community hospitals, with service users rating their experiences as overwhelmingly positive (Davidson et al, 2019). This highlights the acceptance of attending alternative healthcare settings in place of acute hospitals by the general population. In the case of this study, the findings are unique as the target population is paediatric patients.
In England, as part of the NHS Five Year Forward View (NHS England, 2014), proposals were made for a reconfiguration of services, developing smaller hospitals to support acute large hospitals. This initiative was driven by the need to offer patients and their families services locally and to increase capacity in large hospital for growing complex healthcare needs. The drive to use the Nightingale hospital was similar, but was prompted by the unique situation of the COVID-19 pandemic. This article illustrates how other settings could be utilised, while ensuring safety and satisfaction of patients and their families, and delivering high-quality care.
Staffing
The Five Year Forward View (NHS England, 2014) also outlined a vision of new ways of working that challenge conventional access to health care and recognise the need for a flexible, responsive workforce. Guidance is available on how to develop existing services such as nurse-led clinics, however, there is little information providing pop-up services (Hatchett, 2008) Setting up a pop-up clinic depends on the availability of large numbers of medical staff, which would have been a considerable barrier to our service at NHB due to the current gaps in the nursing workforce as highlighted in Health Education England's (2017)Multi-professional Framework for Advanced Clinical Practice in England.
Clinical nurse specialists (CNSs) and advanced nurse practitioners (ANPs) already frequently play a central role in delivering complex care. In both specialties involved in the NHB Butterfly Unit - gastroenterology and allergy – they had a high level of autonomy, expert knowledge and experience, enabling them to take responsibility for a child's care provision without the need for on-site medical input (Hatchett, 2005).
The Butterfly Unit was supervised by a medical consultant and a senior nursing team (consultant allergy nurse, gastroenterology CNS and ward manager or matron). It was supported by the allergy CNS team and day-care unit nurses, and by the bed co-ordinator who assisted with escorting families in and out of the hospital building.
Every member of staff had to be aware of safety and fire procedures. Standard operating procedures (SOP) were circulated. All staff working on the Butterfly Unit had training on site on the fire procedures. The NHB was staffed 24 hours a day by security services for extra support, who were fully CRB checked and also aware of all operational SOPs.
Challenges of setting up a pop-up service
It took determination and vision to implement the alternative service during the pandemic. The set-up took around 4 months. It was driven by the general manager, the consultant paediatric allergy nurse, the ambulatory care matron, the day unit manager and the paediatric gastroenterology CNS, with multiple stakeholders involvement, namely the executive board responsible for NHB, fire services, IT teams, pharmacy teams and administrative staff.
Obstacles to change are inevitable. Concerns largely related to issues moving away from historical ways of working and conflicting ideas about how the service should be run. In this instance, some of the commonly encountered obstructions, such as organisational barriers and those relating to clinic space and associated practicalities, were actually removed by the pandemic. The services had already been stretched and this project, which of necessity had a tight timeline required weekly virtual meetings with the BNH executive board and other stakeholders.
The NHB was closed when decision was made to stand down all Nightingale hospitals in March 2021.
Limitations
There are a few limitations to this service evaluation. In order to ensure a large number of responses, the evaluation form was limited and short. To fully understand the feedback, it would have been interesting to investigate some of the responses further by gathering more descriptive data, which would have allowed a more detailed understanding of the answers. To understand the success of this project, it would have been important to evaluate it from the financial aspect that would assess the viability of such initiatives in the future.
Conclusion
The pandemic provoked significant upheaval within existing ambulatory care services, prompting many changes to traditional service delivery. This article has described how alternative ambulatory services, such as use of the NHB, provided a successful means to manage a potential crisis in access to health care, ensuring continuity of care, safe and effective care delivery and patient satisfaction.
The pop-up service model of care was highly acceptable to families and poses the need to consider the possibility of setting up similar initiatives in future, for example, as potential models for expanding specialist community services. Families were generally happy to attend their appointments outside acute hospital settings. It was an environment in which they felt safe and well cared for, it was more easily accessible than a busy hospital located in the city centre, and provided the clinical team with the opportunity to work more closely with one another than would normally be the case. This highlights the need to identify hospital services that could consider alternative approaches to acute care delivery in future, to ensure continuity in providing equitable health care, in line with the NHS Long Term Plan (NHS England/NHS Improvement, 2019).
KEY POINTS
- The increased workload in acute hospitals requires creative proposals to ensure the continuity of high quality of care
- A systematic, multiprofessional and collaborative approach is needed to successfully deliver patient services in alternative venues to acute hospitals
- Services offered outside acute hospitals are positively accepted by the paediatric population and their families
- When offering an alternative venue, patients and families most value a safe and calm environment, and easily accessible parking
CPD reflective questions
- If patients and their families welcome alternative locations for their care, what are the current barriers for similar initiatives to succeed?
- Would you feel safe and comfortable working in alternative, out-of-hospital locations?
- Which measures are important for facilitating a safe, working environment when considering an alternative location?
- Can you think of any procedures/activities typically delivered in your acute hospital which have been transferred to an off-site location? What are the benefits and challenges?