Managing chaos, doing our best for patients and supporting each other: hospital social work under Covid

Monday 25 January 2021

Our team manager is on leave today so I start early to be prepared. I chair a virtual team meeting at 8.30am to run through patients who are ‘medically stable for discharge (MSFD)’. We catch up on updates from the weekend and today we have over 70 patients on the MSFD list; normally we would have about 30 patients. Working within government guidance from September 2020 means that we are expected to turn patients around from referral to discharge within a few hours, with no assessments happening within the hospital: the model is ‘discharge to assess’ (D2A).

The hospital declared a major incident a few weeks ago; nearly one in two patients in the hospital are Covid positive, there is no patient flow, and pressure on beds, critical care, ITU (intensive therapy unit) and staffing. The hospital increased ITU and critical care bed capacity from 20 to 50 but pressure remains. This morning, most patients are not MSFD, so I run through our patients quickly. Our continuing healthcare (CHC) colleague joins the meeting at 9am to run through CHC-led discharges.

After the morning team meeting, I prepare the statistics for management: daily referral numbers, discharges, and planned discharges for the day.  I note a large number of discharges over the weekend, double our normal business-as-usual figure.

Work has been frenzied since the beginning of December, the team are working valiantly but the level and duration of pressure takes its toll.”

Our lovely team manager has focused the team on wellbeing, with daily mindfulness challenges.

I have the system partners resilience video conference call mid-morning; this feeds back on staff sickness, A&E attendance, admissions, Covid numbers, bed availability etc, so problems can be identified and issues escalated as required. Today, the trust passes on thanks to all partners for the tremendous work in maximising safe discharges in these unprecedented times. The hospital is in a good position this morning although still on OPEL 4 (highest alert); we have patients scattered across multiple hospital sites to manage and maintain flow.

Numbers for Covid positive swab results in the last 24 hours seem to have stabilised after the last few weeks when they were increasing exponentially. At 11.30am every day, the hospital holds a virtual multi-disciplinary discharge planning meeting where the hospital runs through patients who are ready for discharge and we plan discharge pathways for patients. This meeting has become increasingly chaotic as patient numbers spiral and patients are moved around the hospital or to other sites due to Covid.

Although there are over 70 patients on the MSFD list the majority are very poorly and several have died. This is a familiar and sobering experience since the pandemic started but hard to see and hear.

For us, getting people discharged and out of hospital is a matter of life or death because the longer someone is in hospital the more likely they are to end up with Covid, and our patients are at a much higher risk of death.”

The hospital flags a patient who is waiting for a reablement package of care. They were referred to the provider at 8.30am and but by midday there is no outcome so I am asked to escalate this to senior management. After this, our team has a catch-up meeting to receive feedback and plan forward actions; we have two cases to allocate for immediate action. A safeguarding alert comes in relating to a death; we review the information and request duty refer the case to the multi-agency safeguarding hub (MASH) for investigation.

Tuesday 26 January 2021

I have a day off for the interment of my mum’s ashes; a suitably grey, cold day. I reflect on how challenging it is to die during a pandemic; my mother had cancer and wanted to die at the hospice, but she could not receive her end-of-life care there because of a Covid outbreak. That broke my heart a little. I know our tale is mirrored a thousand times over with families losing loved ones in incredibly difficult circumstances, Covid or non-Covid. Grief is challenging during lockdown, when most of the usual supports are blocked by the pandemic. However, we were overwhelmed by cards, flowers and messages of love and support from so many people and that helped a little.

Wednesday 27 January 2021

We have over 83 people on the MSFD list and over 50 on our local authority database ‘awaiting allocation’ list. It’s a challenge to track patients; we have to rely on ward staff to advise when a patient is MSFD but patients can be discharged without our knowledge and without care in place so this feels uncomfortable. This morning we filter out the ‘not medically fit’ (NMF), however, this is not comfortable as the coding is not always accurate. Currently, many referrals are sent to us at the end of the working day or after hours and coded by the hospital as ‘no plan’ immediately; these figures are used to measure our performance so is demoralising.

Today we are down on staff so a colleague has to stand down training; we can’t support training due to Covid pressures. I have a quick catch-up with our manager, who is incredibly supportive. We discuss how pressured things are, how lists are increasing, ways of managing numbers and consider breaking our ‘awaiting allocation’ list to include a priority list for active cases but reflect on the danger of adding a third list into the mix!  We observe that we have no time to pause and reflect and recognise the team’s needs this but can’t see how we can currently.

During some quiet time I track through everybody on the MSFD list (all 83) to make sure we have not lost anyone. I pull out a couple of cases not picked up in the morning meeting and check on their status. Then it’s time to prepare for the discharge meeting. Today all staff have updated information on their cases thankfully. The hospital advises that their database is not accurate; they are unsure if a patient has been discharged or is still in the hospital. This patient needs care restarted to go home, so this worries me. At our 12.30 catch-up meeting I flag new referrals, including those that will need allocation and those that duty will hold and arrange discharge for. Another patient has been discharged so I check with duty that a restart was completed; the worker can’t remember doing it nor the person’s name but it was done. I reflect that this is the reality of hospital social work at the moment, it was a safe discharge but all of us are struggling to hold information in our heads; normally we know our patients and their narratives.

Thursday 28 January 2021

The morning starts with Microsoft Teams playing up, not good when you are chairing! We reflect on the number of patients we have with delirium and how there has been an increase in sudden, overnight resolution of delirium. We try to stave off our cynicism; has the delirium resolved or is this about reducing the numbers going out on the delirium pathway?

Our team manager feeds back thanks for the huge amount of discharges the team is processing and the way everybody is pulling together; they really are a credit to themselves.

Today’s report shows Covid numbers are decreasing within the hospital; the challenge now is for the Hospital to reverse and start to flip wards back from Covid positive to Covid negative. This involves deep cleans, moving patients, frozen beds etc. It means patients move wards frequently and the accuracy of information about a patient is lost. This makes discharge planning difficult. As assessment of care needs no longer happens inside the hospital, we need good enough information from the wards to place people in the right care setting where we then assess their long term care needs.

On the system partners resilience call there is discussion about low staff morale, fatigued staff, concerns about staff with PTSD, delayed grief, reshuffles, and staff redeployment.  The trust remains on OPEL 4.  Our duty team is reduced from four members to one, due to leave, sickness and attendance for Covid vaccinations. We have no staff that we can pull on to duty so will just have to cope. We have four patients who are waiting for a spot purchase D2A bed today, it’s hard to process these quickly but the hospital is quick to escalate to senior management.

We learn that a patient passed away this morning; there is a collective sigh of sadness around the meeting; this patient was well known so there is genuine sadness.”

There are long debates about another patient; the patient’s wife is unsure if she will accept her husband home with a package of care to support, which causes a delay to the patient’s discharge. There is a query about a safeguarding alert for another patient. I check our database; the patient is not known and no safeguarding has been raised so I request that this is actioned by the hospital immediately.

At our team’s catch-up meeting we discuss the patient with the wife who has concerns about her husband coming home; we decide to offer a D2A bed with a view to him returning home with support in the long term. We have a couple of patients flagged to us for referral but a duty worker confirms both are self-funders, so unless there has been an increase in need our team won’t be involved.  With our duty team down to one this afternoon it’s a relief!

Friday 29 January 2021

It’s background Friday where we all try to pick an uplifting background to help us on our way to the weekend. Fridays require good preparation to ensure that everything is clear for our weekend workers at close of play and this takes quite a bit of work to ensure information is clear in our ‘awaiting allocations’ list.  We have five planned discharges today and hope to progress a few more over the course of the day. Blocks from yesterday were wards not answering telephones so care homes cannot assess patients for D2A beds. Yesterday, we expected some referrals, however, none arrived; a social worker advises that the hospital scanners were down. We anticipate the backlog this morning.

Today we have four safeguarding alerts according to the hospital, however, no safeguarding alerts have been received and we are in the dark about the concerns. Work goes into chasing down the information; it seems some of the referrals have gone into a black hole, ie the ward staff have advised there are safeguarding concerns but nobody has completed a safeguarding referral.

For the first time in two months there is some small bed capacity available, our rate of positive Covid swabs in the last 24 hours are half that of the beginning of December. The daily Covid death rate remains high though, and pressure remains on ITU beds and critical care.

At the discharge meeting the hospital advises that scanners remain down and they cannot send over referrals.

There is a backlog of referrals for social services so what do I suggest to resolve the problem? I am mildly bemused that the hospital’s broken scanners is my problem.”

However, I take a pragmatic approach and suggest that they email us patient details, a pen picture of needs and consent to share information in lieu of the normal referral forms; this appears to be acceptable to all parties.

I bounce straight into our post-huddle feedback meeting with the team. We have a care home that has refused to take a patient who was Covid positive but asymptomatic and has completed his 14 days’ isolation. People can swab positive for months after being infected with Covid, but are no longer infectious and government guidance is that they should be treated as negative.

Today, palliative care are under so much pressure they are unable to complete fast-track end-of-life referrals so these patients are stuck in hospital. All our cases seem to on track and our duty team will reconvene at 3pm to go through the ‘awaiting allocation’ list to make sure information and actions are clear for our weekend workers. Our weekend workers complete email summaries for us to pick up on Monday morning when we start the week again by pulling together all the different threads of patients, lists and information.

Sometimes it seems like a never ending battle to manage chaos, do our best for our patients, and take care of our wonderful team of dedicated workers who have worked flat out every single day of the pandemic. I can honestly say that they make me feel so proud of them; their skill, dedication and their humanity.