EXCLUSIVE: Westmead Director of Nursing on fighting COVID-19

Kate Hackett is the Director of Nursing at Westmead Hospital in Sydney, ground zero for the treatment of COVID-19 here in Australia.

Like everyone else, Hackett had seen the virus develop from afar over the summer period but could not imagine the situation we find ourselves in today, with nearly 350,000 confirmed cases and 14,000 deaths worldwide.

The week coronavirus became real for Australians is fresh in the memory for Hackett. She came back from leave on 20 January and it was on her doorstep within a week.

“My initial thoughts were ‘how big could this be?’ And I don’t think we could foresee back in January the position we are in now,” she says.

And like everyone else, Hackett couldn’t imagine that the virus would cause the health, social and economic disruption that we see today. She describes this period as the “most exhausting two months of my career”.

You wouldn’t know it to talk with her. Immediately positive, Hackett has approached the pandemic as a once-in-a-career learning experience for her and her team.

“It was a lot of learning, I suppose. That first patient then those first four patients arrived within a short few days, so it was a big learning curve for us. And I'm obviously reaching out nationally and internationally to seek advice,” she says.

Westmead is one of NSW’s designated infectious disease sites, so there was no shock or anxiety surrounding the emergence of the virus. The doctors and nurses involved are all well versed in PPE and protocols around highly infectious diseases.

Nurses involved with positive cases of the virus wear gloves, a mask, face protection – shield and/or goggles – and work in a patient’s isolated single room with negative pressure – where the air is sucked out and not recycled throughout the other areas of the hospital.

They also follow a strict process of “donning and doffing” their PPE to stop an infection spread.

“Staff have been always willing to look after these types of patients. So I don't face circumstances where staff feel anxious or not trained to look after these patients.

"I think the nursing staff have really taken it in their stride and we update them regularly with all the information we have about the disease. And we also do a lot of progression training,” Hackett says.

Nursing Review talked with Hackett about how this virus is affecting her staff, day-to-day care at Westmead and some tips for hospitals yet to come in contact with COVID-19.

NR: What does it look like from presentation to treatment and what are the differences between this and normal procedures?

KH: If a patient presents we have two ways in for positive patients. If a patient presents with symptoms and they need a level of hospital care, they'd obviously be tested for COVID-19, along with a wide range of other respiratory illnesses if they've got respiratory symptoms. And while they are awaiting their results, if they need hospital care, then we have a unit set up where we isolate those patients. And they would wait in there for the results and obviously be receiving that hospital care.

We've got a lot of patients with comorbidities. So, it might be that they're unwell due to their renal function or they've got cancer and they're having other treatments. They would go to our COVID unit and obviously commence treatment for whatever symptoms they've got until that result comes back. If they're negative, then they're moved out of that unit and just remain receiving care by the specialty that they should be under.

If they're positive, they remain in that unit we have, continue to receive the hospital care they require, and obviously once we've treated whatever they needed hospital care for, they would be discharged home.

Now as it stands, they might still be positive when they're transferred or discharged home or they may be negative by that stage. So, we've had both of those scenarios.

The other way positive patients may come into a hospital is if someone is being flagged in the community and then they get a call from public health to say their result is positive and a decision is made, I suppose, where they look at the contact they've had in their home situations. So if public health feel that they need hospital care, whether it's just the isolation reasons or they're unwell, then they will be transferred into the hospital and we transfer them straight into that COVID ward.

Is the level of PPE and infection control higher than normal or has nothing changed?

What's changed is really our refresher-type training. All our nursing staff are trained in PPE already but I suppose it's that timely reminder. That's where we have a lot of educators in infection control staff around the facility, ensuring that the staff feel trained and supported and they can answer their questions if the staff have any about, for example, 'Do I put the gown on first or do I put the mask on first?'

What is the advice to the patient when they leave and how have you charted the recovery of the patients who have subsequently recovered?

Normally infectious diseases call when that patient can go home. Public health and infectious diseases would determine what that patient needs to do if they are being discharged, in terms of home isolation or other things like that. That's not really a nursing decision. And as I said, some patients leave here still positive, then some leave negative. So, the advice would obviously change depending on the patient and where they are at with the COVID-19 disease process.

In turn, they are then followed up at home or they come back to our clinic to be re swabbed. It just depends on their disease process.

And also, if there are any other co-morbidities or other factors as it's often just not the respiratory symptoms, our patients will come in. There are chronically unwell medical patients, diabetes, cancer, renal disease, pre-existing respiratory issues.

COVID is often just one part of the whole piece and obviously how we continue to recover them in their homes from those other flareups in their comorbid diseases is important as well.

How has the hospital been forced to adapt? Has there been a strain economically or on PPE, etc?

I think the hospital has adapted really well. As I said, I think people have got on the bus and got on board. And I think, when you work in a major trauma state-wide quaternary centre, that people like new things, they like change.

It's an evolving disease. We have supply of PPE, we're working obviously very closely with our suppliers around that. But our stock levels are fine. And it has taken extra workforce to staff a COVID-19 clinic and a COVID-19 ward. But I think also, I'd say, given the size of the hospital, we've been able to absorb that to the point very well. So, we haven't had any real concerns at this point with staffing.

I imagine leave has been cancelled and perhaps extra numbers of nurses have been put on. Can you talk about the numbers that have been put on?

In terms of leave, there was obviously a directive from the Ministry of Health around reviewing leave over the next six months. Our local managers are obviously looking at people's leave, but I personally haven't seen any cancellations at this point with nursing. I suppose we're a little bit fortunate that we've come out of that December, January period and a lot of our staff were able to have a break during that time.

We are just continuing to review our rosters and our leave allocations at this point. And obviously that broadcast has gone out to all our staff. Just really considering leave over the next six months.

We’re unsure exactly how it could look in two weeks, six weeks, three months. So, it is a fluid situation and I think our staff are aware of that and also understand that. And what I'm finding now is obviously with the travel ban, they're not able to go overseas. So, I'm getting more calls to say, 'I can't go to the UK, I'm happy to cancel my leave and I'll have it another time'.

The government announced that the restriction on the 20,000 student nurses is going to be lifted, It that helpful?

I think there are pros and cons. I think pros are obviously sets of hands and part of the workforce. I think the cons would be that, I think we'd really need to see what the students could do and whether the tertiary quaternary-type hospital is the right setting for these students. Or is it a deeper part of their healthcare environment that their skills and their abilities would be better suited to? I think there's obviously a fair bit of work happening behind the scenes around students.

Obviously, we need to ensure we're putting them in a space where they're working within the scope of skill and whether Westmead is the right setting for that.

I know that you’ve said you are well set up to tackle infection, but this is something totally different. How are the nurses coping physically and mentally? As someone in charge, how do you keep anxiety low?

Yeah, good question. We’ve had nearly two months of COVID-19 now and I think the bulk of nurses here have had some exposure to what's going on at the hospital. But my focus is predominantly with those ones that have been working in the clinic and the COVID ward and the AD and the ICU, that have also had workload due to this. I mean we've tried to keep our ward business as usual a little bit.

I think overall the staff are feeling well supported. That's the feedback I get from going into these spaces each day. And I think it's on us trying to keep the morale up. I think the education and training piece, particularly that PPE and the disease is really important to them. A lot of the feedback I've got is about just communication and information sharing.

So we put in place with the CE daily communication and broadcast to all staff, so that everyone is across the latest information, because I think a lot of anxiety can come from people not knowing what preparations the districts put in place in the hospital and not having the most up to date information.

We huddle at unit levels and a lot of that information comes up to our facility operational COVID meeting, which we have each morning. And it might sound like really simple things, but the things we need to consider and the things that are important at the front line.

How are the nurses coping outside of work, with school closures, shopping, etc?

Our nurses are working really hard at work and trying to juggle their homelife. I have two primary aged children and trying to decide whether to keep them at home or send them to school. And, yes we’re essential workers, but there is a level of parent guilt I’m hearing from my staff. We don’t have the luxury that we can work from home at this time; we need to be here planning. And that causes a lot of stress with staff.

They’re also concerned about their ageing parents. I have parents in their 70s and I’m concerned for their welfare. I think the staff are tired… we’ve gone from a bushfire season straight into COVID, so there is a bit of tiredness. And then, they go to the shop and they can’t get everything they need, so that adds a bit of pressure as well.

Are there extra mental health supports available to staff?

Yes. We’re doing a lot of work around wellbeing and culture and we have an employee assistance program. So that is a phone or face-to-face service to support staff.

We are also making sure staff walking around are checking in with staff, asking the questions; 'Are you okay?’, ‘How are you travelling?’, ‘What can we do to help?’.

You and your workforce are best placed to talk to this because you're the first hospital in Australia to deal with it. But for any nurses and health departments around Australia who are yet to face the virus, what would your advice be?

My advice is to seek information and support from your peer hospitals. We're all learning from this, and I suppose there's people and organisations that are at different stages of their planning and work in this space and I think we can all learn from each other's experience. I think that's really important to communicate across hospitals.

My other bit of advice is the team. Having a real crack team of senior clinicians and infection control experts, hospital executives, public health. Looking at the first particularly six weeks of this response, it's exhausting and not one person can organise or facilitate this for an organisation. It does take a team of highly specialised people and I suppose as a leader, my job is bringing that group together and make sure people are heard and come out of our huddles or our teleconferences with an action plan and a way forward, and reassuring your team, but also your wider staff base that we have a plan and what we're working on and providing that communication back down to every level of the organisation – exactly how we're placed, what we're working on and listening to their concerns.

Editor's note: Nursing Review would ask everyone to be extra compassionate and grateful when dealing with nurses (and any healthcare workers) through this period.

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